HomeMy WebLinkAboutPermit Plumbing 1995-7-18
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BACKFLOII PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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, ASSESSORS MA~ 11:, \\(Y~~,~.A~~ - TAX LOT 11: en \r()
OIlNER: \U\~\\()M .\~~(\O _ Ll
CITY:~~X ~ - STATE: ~ \i~~ ZIP: q~ll
BACKFLOII PERMIT IS $15.00 ~ $;~5 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CO..meTOR' ~ '-cM.l\C\ 'iI.'Jl.iR..J
ADDRESS'~.l~, \L<K~ 1- ,(\ Ir,/HONE 11:
CITY: - ~~Qfi) STATE: l\l.L.-
.cONSTRU~TI N CONTRAC\~ REGISTRATION 11: l.Q l ()q 9
ZIP: ltl4-]].
EXPIRES: ~..30.q(p
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII 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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7-!r;~?f
DATE
FOR OFFICE USE
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TOTAL AMOUNT COLLE~: _ _ ~ ~. 'L()
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