HomeMy WebLinkAboutPermit Plumbing 1994-8-2
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SPRINCFIELD
BACKFLOW PREVENTION PEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location:
731 04. fJ t( ( Ai c&4/ ie-1 if
Assesso~ U: I 7 [) ~ 2.7-::>"/
Owner: .... 10M. \ /~0V..SL-
Address: ( (15 J>elo vi L-k- e..J
Tax Lot U:
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Phone U:
3~ ~ Sfo 72-
Zip: 97<{O I
City:
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State: tJrZ-
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Backflow Permit is $15.00 + $0.75 State Surcharge -+ 3"h
Contractor::r:-~ 1 J~A A, s C!.ore--
Address:7LI S5'<;{ I ~A{/'.+--HI\D"AJS ~
City: r;-lA.~ State: ('fyL.
C~nstru'ition Contractors Registration II: (p ZJ? I
Phone II:
747-- :2/iL{ (~
Zip: Q'7L(oC;
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention devic.e ha,s 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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SignatuMr"
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Uate
FOR OFFICE USE
Date of Application:
Receipt U: tl.\\ ~()
Total Amount Collected:
6'-7_4--1.
Issued By:
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Job If: q L/ fy-lrx-c;
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