HomeMy WebLinkAboutPermit Plumbing 1994-8-2
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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:. (Oq~CL fof5 /If rJ tll!-P/( (.I-&1/f
Assesso~ D: /7 o"3Z.}.~1 Tax Lot D:
Owner: ,,10M. \ /I^-;~
Address: (! 15 J>eb vi c...k- eJ
(f/ulJ
Phone D:
3'1 :;, SLo 72-
Zip: 97'{O)
City:
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State: DfZ.-
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Backflow Permit is $15.00 '" $0.75 State Surcharge -+- 3~ (.45)
Contractor: ~VZJJ..d 1 jJ-.tA J s c,o.fX?-
Address :7L/ <t<;{ I Mli\+-f\AD iIA) S J2j
City: r;/lA~ State: (Ji/L
Constru~tion Contractors Registration D: to ZJ? I
Phone n:
747- =;/1L[ (~
Zip: Q7t(oC)
Expires:
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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lJate
FOR OFFICE USE
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Date of Application: ~~ 7-{-9J Job D: q 3/ 7D-;2.,'
Receipt D: \~ j 3777 Issued By: ~lA~
Total Amount Collected: lJ.(J, z>>
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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:--1L95"- ~91 (I~ /~
Assessors Map 0: /?-.6'3~2..~r Tax Lot 0: ///t::>P
Owner: ,)~ ?~~;;(~ ~ /7'D
~::;:~~~ st"" of! Ph,,, I,
(/ , "
Backflow Permit is $15.00 + $0.75 State Surcharge~ y~ d'. ~
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Contractor: ~ l~ ~,A'M2A.
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Address: '?i 8 go I t1 ~ ~,,/
City: ~ State: (!);q
,j (/ , '
Construction Contractors Registration 0: (p~ 'i; /
3V3~~~~
ZiP:.it?-~~
Phone 0:
717 -3'1'16
Zip :.JL'IO S-
Expires: 8'-3/-9 'I
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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7 /~ /9'1
Date
FOR OFFICE USE
Total Amount Collected: ~~~
Job D:
/2--
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9'3/703
Date of Application: ~...9'1".
Receipt if: n././ -' Issued By:
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