HomeMy WebLinkAboutPermit Plumbing 1994-7-6
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BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: 7f1.'7-7:J':;- (I././t'1J'OtJIA( ~
Assessors Map U:_ r7~~" 2::2-'7/ Tax Lot #:
Owner: }...vYn tYl ) ~ y /L.~
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Address: //?S--Z::> t!"";9~Lr-4- Phone U:
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City: 6- /~cA'/~ State: O./=r' .
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Zip: ~') Y~I'"
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Backflow Pennit is $15.00 + $0.75 State Surcharge ,..:;J-::;'b.t:1. ~./-
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Contractor: ~.~~.r>1k41'1
Address:..1...'f~~/ 11._~M.. &J
City:~~ State: Of?
Construction Contractors Registration II: (~C2 ~I
Phone U: 7 '17 - 3tj '16
Zip:$7VOS-
Expires: ';-/3;/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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Signature
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FOR OFFICE USE
Receipt U: A././ ~
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Issued By:
Job D: .qV;!!:'S/~
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Date of Application: ~.9cr .
Total Amount Collected:
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