HomeMy WebLinkAboutPermit Plumbing 1994-9-7
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SPRINGFIELD
BACKFLOV PREVENTIOij DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: 2-~&.'7 S ' C--~}/LXLL7rF. L-tJ,
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. ASSESSORS MAP It: /76):S :::2- 2- 4 S TAX LOT It:
O~.ER :~-rY.? /h(' /- d( C::A--u~~
ADDRESS: ~<gD 2.. / /~ d/.. p,z b.J _ PHONE It:
CITY: .Eut:i4.:J6 STATE: c:;Pf',
c?<1?~C;O
~ S~ - 5"2.7(".
ZIP: 97-;1a 2..
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: #/ ~/7E;Tt/ AJ,.e~rj; '77N
ADDRESS: ,'4 /J /~]'x'" 4c; i
}/ bvEJ?/.-
9 ?,5"-32./S
ZIP: 97~6 '/
EXPIRES: <;i/.Ya-;/::>J
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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. .
PHONE It:
CITY:
STATE:
D<-
// S 72.
CONSTRUCTION CONTRACTORS REGISTRATION It:
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1'-7-..9'7
DATE
FOR OFFICE USE
DATE OF APPLICATION: )>1 ~//cI-
RECEIPT It: i# S J ISSUED BY:
IF _ _2..0
TOTAL AMOUNT COLLECTED: ~ .
JOB It: q1J3 7 g
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