HomeMy WebLinkAboutPermit Plumbing 1994-7-8
-
.
.'
SPRINCFIELD .
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING, SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location:
(' b'J)'UJA~ 0
Assessors Map U: /?..g;?-,;?C.- 5~ Tax Lot U:.~':;:'
Owner: .Ja..I'~ ~ f' Jg.vn, m.tnJ'l/Y\
Address:.,.2,t) '7~- WI1A'~
CitY:4.l.AQ.J; State: f?/?
t7'f- fo7~
Phone U:
'f'if''f - / /l~ i
lip:J:Z::IO~
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~'./\/tjd ;;I A/YI.d~.aA...
, f/
Address: .1'i'?tj('1 ~~ f?q
CitY:~ State: (lJ/f
v 1; ,
Construction Contractors Registration 1/: Id::l fr- J
Phone 1/: 7'17-.r~'1~
lip:.:t...7Y05
Expires: ff' III /91/
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that an information on this application/permit is
correct.
[' kA ITY1 151 / -AA'.1~
Signature .~H ' ,j-
7 / rr- / '1'/
1Jate ,
FOR OFFICE USE
Oate of Application: ?..g..~t,I ,
Receipt 1/: ~8 Issued By:
Total Amount Collected: I'~- :? ~
Job U: '9l/ /6'/$
/?,!,,>,"~ ~
~.i'1ll".~'" ------ -
'/