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HomeMy WebLinkAboutPermit Plumbing 1994-8-8 ---. .0' , 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: '7fJb - '7{jy A/ {i/rJIJ-pf'/OO-{ Ln. 1 Assessors Map U: J'7cn Z;L .( f Tax Lot U: o9dO'O Owner: ra nd v Va Ylrl-LJI Z (/)1 d~-n i. - Address: YI'(" JI1YJ"l:]e tlf (Vf Phone U: City: ~pr l71j -h ~ /,,/ State: CJI? Zip:..l2V77 Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: ,E 'h? PI 0 / cI l. a 7'1 c!." r. C( ;J e . ' Address: 3'1i?R/ 114r/yI'W5 Rei State: rrJ/l. - City: t:: u (. P YI () 0./ - ,j . Construction Contractors Registration II: 0 -;) II'" / Phone 1I:.J-7'7-3'tYC, Zip:-22.'10<;",," Expires:..f' /3/ !..:lY 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. /:~ "/>A .A-./1 () '( -"/'~.A~ Signature (} ?/ fid-~<-/ FOR OFFICE USE 'I Date of Application: cg,/?-S-I'j'c/ Receipt U: Jd2.43 Issued By: , Tota 1 Amount Co 11 ected: / /:. 2.. l) Job II: q4/ Z,/f) /~,.