HomeMy WebLinkAboutPermit Plumbing 2000-10-6
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SP.~IELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: L-f d-. &'-\ (0 \ L W C>\ V
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. ASSESSORS MAP II: I >(Q;;:( 05 :+.. 4
OIlNER: :;; a r ""' \..\-.:? \rIr-~ 5
ADDRESS: 4.31 q,~ [\/\'Hr(),,: 'Z.L iLl
CITY: (' N.S WL ~\ STATE: V'?-
TAX LOT II: (X;9(XJ
PHONE II:
ZIP:
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50
CONTRACTOR: 'De..c..k.! r L""V"\J.s c.c..P'l..... ",~J .f..J'<-,'",l7\\-io'"
ADDRESS: r.o~ 13oi- C61 PHONE II: 'i'LfI-1,1>~-7'1<11
CITY: Alu",c9or'l. ~ STATE: 1J R ZIP: C]740'l
CONSTRUCTION CONTRACTORS REGISTRATION II: (" 71.../ (Q EXPIRES:
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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10- c,--- )-OoD
DATE
FOR OFFICE USE
DATE OF APPLICATION: \0 k f('jcJ
\ / .
RECEIPT II: .~t.j "')...() ISSUED BY: W,c,
TOTAL AMOUNT COLLECTED: -1 I~ .';)(5
JOB II:
DO-O()1J()O - 01
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