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HomeMy WebLinkAboutPermit Plumbing 1994-7-6 ~. ..1 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 I v ' tJ~ Assessors Map 0: /"?~3 ~~ -$/2. Tax Lot 0: P6o/t:::'t:? Owner: ,)-'~ ,... ,J~ ;tu ~ /~I'~.E?'9' ,- - "/ / , rT..... --<? Y"? Address: /4"// t4UG~ 7f~ Phone O:J!j1-,"'-t, 9:/ City: c:bd8~C State: ~~ Zip: ~~/ .' Backflow Permit is $15.00 + $0.75 State Surcharge~ ~~ , \ , Contractor: E-"YYJ ~ ~/cI h (/.}uft; CO D P . , Address:-1-lf~~1 !1atf,.Plo<; !?d City: E 1/) (> 1'1 p State: of? ,j , Construction Contractors Registration D: ~l~/ R.Y? 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. " ,~ ~"'-'r~ Signature "cJ r t / k fry o te FOR OFFICE USE Date of Application: ~9"'. Receipt 0: /3 '/ / / Issued By: Total Amount Collected: /h~'2C> Job 0: 9~,::1::i24/ ~---~ . 7----- ~