HomeMy WebLinkAboutPermit Plumbing 1997-6-18
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BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225'FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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,ASSESSORS MAP #: 1703;}.J..51../ U TAX LOT#: IJO;<C7
OiINER: ~ ~ --
ADDRESS:' ?5"S-7.1R' 6)'1//(~ IZd PHONE #: 7J..(rJ -/C;J. S
CITY: .... ~Ilha.- Cl &J... STATE: ~ ZIP: G-ici77
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BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN.
CONTRACTOR: ~~ Q
ADDRESS: ~)CI'2~L{
CITY: ~Dr-1 r\r_ (2.,("".d) cA STATE:
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CONSTRUCTION CONT~ORS REGISTRATION #:
FEE) = $16.20
PHON #:
~A , ZIP:
, (,., (~ 0) &jEXPIRES:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. ' .
SIGNATURE
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FOR OFFICE USE
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. DATE OF APPLICATION:0--(g-- 1'7
RECEIPT #: 2.foJ1;?i/j ISSUED BY: W
TOTAL AMOUNT COLLECTED: /.0, ~
, JOB #:
q 70C!i/G
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