HomeMy WebLinkAboutPermit Plumbing 1996-5-3
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SPRINGFIELD
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
IlUILDING.SAFBTY-DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ,[) C').. '( i- .2 G 15
" ASSESSORS MAP II: 1,02, do;:?- '34-
O~NER: . i~ <<i ( ;! ()", ~ I J.-~>
ADDRESS:.~~ 728f;r2./IIl]: gee
CITY: ~A)ro-
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TAX LOT II: ood-(j()
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PHONE II: 7z..Cp'-
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'17 ~77
STATE:
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ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR:
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ADDRESS: I () '2. 0 V pi(
CITY: 7f1'h~1:t:ek..e
CONSTRUCTION CONTRACTORS REGISTRATION II:
(v.",,j rc e(le
V\, <)'1, ' PHONE II:
STATE: Ot?,
/1840
7r..r'r - (ro >
ZIP: cf?4'('(
EXPIRES: q-'11 - erf
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
IlACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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'SIGNATUJ/ -
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DATE
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FOR OFFICE USE
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DATE OF APPLICATION: -<-3- 9& JOB '1I:'6f(POI ft;~
RECEIPT #: Q2../37Lf' ISSUED BY: Y\ . m. ~;"^ d,-Lo
TOTAL AMOUNT COLLECTED:.$ ((d. ')0
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