HomeMy WebLinkAboutPermit Plumbing 2001-4-9
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CHANGE:
CASHIER: 001
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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. ASSESSORS MAP II: I 'if' CJ ).. ())- -;2 '-I I
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CITY?@D,tfti>>J~'tfo);~.~:;ru~~~ v. STATE: ZJ'I'o..-J THISPERMITSHALtf{p":iP',7W9EL'4ZiRK
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BACKFLOV PERM1:T'IS $15.00 + 1.05 (STATE SURCHARGE) +C~~~t-~~bgI~~I~~~rN2r{f:~gOR
AI~Y HID OAY PERIOD.
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CONTRACTOR: ",)..(~ /1'1 ( ~ f'
ADDRESS: . -=?Sio I ....-f/JOD ~ I)'/'€..
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CITY: C, ~QM.L . ()-?P _ r 7<;l'1L~ STATE: /)~ 0'.
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CONSTRUCTION CONTRACTORS REGISTRATION II: I.? f 90'3
JOB LOCATION:
TAX LOT #: t, tj (J(j
PHONE II:
'370- S887
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ZIP: 9710.')
EXPIRES: /"</;210 L
BY SIGNING THIS PERMITfAPPLICATION, 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
FOR OFFICE USE
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DATE OF APPLICATION: 04 - o~ - 0 I -
RECEIPT #: t1I)(-;7;:1
. JOB II (\0 CY...J:'J 7 'l - 0 I
TOTAL AMOUNT COLLECTED: \ ~
ISSUED BY: r::s . \1r\ M r\ k <>--n\ >.::>
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