HomeMy WebLinkAboutPermit Plumbing 1997-6-18
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225. FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION:) (J.L~ &~ at;. 63 / 2~(J5"" .
.' ASSESSORS M~ j/: ./ 70 3:( '(j73~'CJO::2f) 2. ___ T!X LOT j/:
OIINER: (hI 'u r Q ~ ),j
ADDRESS: '?5$?7~3'~6M; ~ ed
CITY: ,S<;PI.2.-~ h~/cI STATE:
PHONE j/:
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ZIP: 67c(" 7-
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: - ~ (f}11vi "1 '''\."1 djc:.rjf ~ ~ ('oJ"'-----1'
ADDRESS: ~() Y-rsvJ' IQ K 1 PHONE j/:
CITY: S'Piui\~-'~ '12r ~Q i2ld . STATE: ()R~ ZIP: O~.~rLrl
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CONSTRUCTION CONTRA ORS REGISTRATION II: ?:-~9q EXPIRES: ~/4r)/9<;t
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT.
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DATE
SIGNATURE
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. FOR OFFICE USE
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. DATE OF APPLICATION: 0- If) -0; 7, JOB j/: VI 7!1J'f7
RECEIPT j/: 2!t723t/ ISSUED BY: 'lAL" ," .
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TOTAL AMOUNT COLLECTED:
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