HomeMy WebLinkAboutPermit Plumbing 2001-4-9
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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rCITY:tJFj)lfW)(f\IJ'~j',:~~~0.0I;;~~',J STATE: (109JY 180 DAY PERIOD: ZIP: 974')...Cj
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BACKFLOV PERMIT IS $15.00'+ 1~'b5 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
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CONTRACTOR: ~[ -""="u .:L:.~ 1~:)K#U?kY~~
ADDRESS']'b,'{).' ~l~"~..,.orril ,44>12.. PHONE /:.$f+3 5liS:-'#f-lIJS
CITY: r J Co~ STATE: (()Q f) . ZIP: 7/<;0 ~
C~NSTRUCTIO? CONTRACTORS REGISTRATION #: 1.3 J 9 '0 ~ EXPIRES: !.?/:Z '3/0 '(,
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION.
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. '
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SIGNATURE
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DATE' 1
FOR OFFICE USE
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DATE OF APPLICATION: 4~07 -01 JOB #:C)(J t)t!Jo7Y 6 J
RECEIPT #: LjJJ7Y ISSUED BY:h . maMa"h
TOTAL AMOUNT COLLECTED: /(0. ...,'1!)