HomeMy WebLinkAboutPermit Plumbing 1994-7-6
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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:-3 O~... U/ U;'HA.tt-a// ~
Assessors Map II: /)",t:>~- ~<-7~ Tax Lot Ii: /./7esz::>
Owner: ) ~ 'f- )".k, y", aw.
Address: //,'J<::;' Pt5Ji9~./~ (~7.:). Phone 1i:.-1....'I ~ -<,-t.z.-92
City: ~~~ State: ~/~ ' Zip: C;::j":;? ~/
Backflow Pennit is $15.00 + $0.75 State Surcharge r.)~ 4>. ~
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Contractor: ~l/1~d ~
Address: ? 'f~'i<:/ 11 ,.ti..t-U~' I?d
City: f:~.) State: 0 I?
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Construction Contractors Registration 1i:~:2 f? /
Phone 1i:...2y7- 3rt '/ b
Zip: '1 ?y~rr
Expires: ~-31 -9'1
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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!ignature
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FOR OFFICE USE
Receipt Ii:
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Issued By:
Job Ii: '9 (,/tt::;:?2':?
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Date of Application: '?-.6~~,
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Total Amount Collected: /~:z 0-