HomeMy WebLinkAboutPermit Plumbing 1994-7-6
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BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILOING, SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: r. 7/ - (. 7 3 (' .J.mx;'.luJ 1 ~ .r ~ 1.'.1..4
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Assessors Map 0: /"?~3 ~~ -$/2. Tax Lot 0: P6o/t:::'t:?
Owner: ,)-'~ ,... ,J~ ;tu ~ /~I'~.E?'9' ,-
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Address: /4"// t4UG~ 7f~ Phone O:J!j1-,"'-t, 9:/
City: c:bd8~C State: ~~ Zip: ~~/
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Backflow Permit is $15.00 + $0.75 State Surcharge~ ~~
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Contractor: E-"YYJ ~ ~/cI h (/.}uft; CO D P
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Address:-1-lf~~1 !1atf,.Plo<; !?d
City: E 1/) (> 1'1 p State: of?
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Construction Contractors Registration D: ~l~/
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Phone 11: 1'17-79 '16
Zip:..i2.'10S
Expires:_Y'/J/ /r..z::.
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
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Signature "cJ r
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FOR OFFICE USE
Date of Application: ~9"'.
Receipt 0: /3 '/ / / Issued By:
Total Amount Collected: /h~'2C>
Job 0: 9~,::1::i24/
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