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HomeMy WebLinkAboutPermit Plumbing 1995-7-18 , :. .., .. BACKFLOII PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINEI 726~3769 :::-::::~:::~--~-~~~-~-&~~~-~~~&OQ;.t:~~t~~:~--~-- , ASSESSORS M':P D,: \ t\~~~ . _, ",TAX LbT .i~) OIlNER: \\.)~\\\ClJN\ ~~ ~CW .' .' , ADDRES~Y\17$o~ 1" ~ ~~ ~ . "t>IiONE III LLJo.\~1.3 --d CITY: ~oQ rtJ STATE: ~ ' ZIP: Q'14l tJ BACKFLOII PERMIT IS $1~00 + S.7~ (STAtE SURCHARGE) + $.45 tADHIN. FEE) = Si6.20 CONTRACTOR: t,/1' f\~ Ci'Gfl:L ~ ADDRESS:~ ~ _~2.~1 ""..--r _ - ~iIbM~ 3! CITY: .J10 ~ ~ STATt:!...'~ _, CONTRACTO S~EGISTRA'rION D! tclcRC1", .. ',' ,2U! Cf141J EkPih~!;!ct.C3CJ ~~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE to CALL ~OR AN INSPECTioN ONCE THE BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED ANti is VIS!BLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THis PERHITiApPLieATION IS CORRECT. . ,\~ St'GNATURE blT~ ' " Fait OWfCE Ugft ----------~----~----~-~~~~~~-~~---~/1~~i~-L~~~~-----------~~~--~~~~~=~~~~~~~=-- DATE OF APPLICATION: ,,,\ .., ~ ~:.~ \.; L. I ,~II! q 4 \ td<l.o RECEIPT D: \ ~'3~O ~s~ BY: \:. ~ TOTAL AMOUNT COLLECTED: \l.o, 7f.) --------------------------------------------------------------------------------