HomeMy WebLinkAboutPermit Plumbing 2000-2-24
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SPRINGFIELD
707
00
.50
CHANGE:
CASHIER: 001
BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATIO~
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: I L--b CtJ trJ ~ Pr-t f2-\! I l("W DtL--1 If 'f:.- '
, ASSESSORS MAP #: I 'I ('j '3 Z- 7 '3 I
OIlNER: JIl.--l-- f-tb'i ~ (..--A---
.
ADDRESS: /1-3.G W fAt ,e..1I1 WJ Dr2--d((...
CITY: <;;;('K-ll\I&f\ ~LO
TAX LOT #:11LIO ~
STATE: 0 K-
PHONE 11: 7"2,.." -}< 67 g--
W: <'Jg'l-'-(70(P'
ZIP: "'/7. '--f 7'1
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR:
Sf6'-'r
ADDRESS:
PHONE 11:
CITY:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT. '
""V~~
'2-- ~l/-(} 0
DATE
FOR OFFICE USE
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DATE OF APPLICATION: :;;r/J---,efl (J7) JOB #: (}()()OOOsoJ
RECEIPT #: 1m. ISSUED BY: IJ . fYJa(}M du
TOTAL AMOUNT COLLECTED: .JJ; / D, so
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