HomeMy WebLinkAboutPermit Plumbing 1994-8-8
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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: '7fJb - '7{jy A/ {i/rJIJ-pf'/OO-{ Ln.
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Assessors Map U: J'7cn Z;L .( f Tax Lot U: o9dO'O
Owner: ra nd v Va Ylrl-LJI Z (/)1 d~-n
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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
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Address: 3'1i?R/ 114r/yI'W5 Rei
State: rrJ/l.
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City: t:: u (. P YI ()
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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.
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Signature (} ?/
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FOR OFFICE USE
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Date of Application: cg,/?-S-I'j'c/
Receipt U: Jd2.43 Issued By:
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Tota 1 Amount Co 11 ected: / /:. 2.. l)
Job II: q4/ Z,/f)
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