HomeMy WebLinkAboutPermit Plumbing 1994-7-6
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SPRINGFIELD
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: '1 LIj - 7 ,j'f U.h1tf.A.lu.! ;I~
Assessors Map U: /?--&:>~-<--:2. ~ 7/ :rax Lot U:
Owner: )..lhYl &1 .) ~ b. ~
Address: 1/7S"" pC7'1n~ ;:::?'.z:> Phone U:
d!3'Of::=7~ f1/,..t;; State: C::::::>./? .
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City:
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Zip: q":)~
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Backflow Pennit is $15.00 + $0.75 State Surcharge r ?..""
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Contractor: ~./I ".J.-! ~
Address: 3 y f~ I 11" ti aJbL 1<-..1
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City: ~..t. State: to/?
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Construction Contractors Registration U: ';t~/
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Phone u:_Jj7-sq,/?, _
Zip :37'f O.s-
Expires: 5'/3/ /9'1
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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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"1 1f4 /97'
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FOR OFFICE USE
Date of Application: ~~~.
Receipt II: .~ ??? Issued By:
Total Amount Collected: /6, ~
Job U: q~t:::' '7'95'
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