HomeMy WebLinkAboutPermit Plumbing 1994-8-2
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BACKFLOW PREVENTION PEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING, SAFETY DIVISION
225 Fifth Street
Sprjngfield, Oregon 97477
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Office: 726-3759.
INSPECTION LINE: 726-3769
Assesso~ 0:
Owner: "i0M \ )J..J~
Address: (115 Y-e..lo vi u:- gJ
72t5~127 Ai d~lLf!fJ .
l!Zl3:JS1 ~ Tax Lot U: [3S6u
Job Location:
Phone U:
3~ ~ 5~ '72-
Zip: 97t{o)
City:
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State:
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Backflow Permit is $15.00 + $0.75 State Surcharge ~ :3~
Contractor: r:-~ 1 JJ.-/.A I') S 0-4pe-.-
Address:3LJC)y I MU\--l-<-H^o.w') IZtJ
City: r::;'lA~ State: ~
Constru~tion Contractors Registration II: 1.0 z.;? I
Phone R:
747- ::S7L( C
Zip: q'? r{b~
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow preven~ion dev.ic.e has been installed and is visible for inspection
(726-3769). I also state that all information I3n this application/permit is
correct.
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SigMt'ure
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FOR OFFICE USE
Date of Application:
Receipt R: \I.\~\o 0
Total Amount Collected:
S" - 7_ .Lj'.{
I ssued By:
Job n: q 40 4 '--IX'
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