HomeMy WebLinkAboutPermit Plumbing 1996-5-3
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SPRINGFIELD
BACKFLOII PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING.SAFBTY-DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:
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STATE: ~O_
,TAX LOT II: V () J (J?)
" ASSESSORS MAP II:
OIlNER: '(7.( \ I
ADDRESS: g CO 72.- <is
CITY: ~PO
PHONE II:
343 -(g:;>o d-
ZIP: '77~71f
BACKFLOII PERMIT IS $15.00 + $,75 (STATE SURCHARGE) + $,45 (ADMIN. FEE) a $16.20
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CONTRACTOR:
ADDRESS: \D'LD lr-el{ IlL PHONE II:
CITY: 0l-1\1 '\",r/"'t"(cl STATE: oe,
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CONSTRUCTION CONTRACTORS REGISTRATION II: i (~( C(
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ZIP: 91';Cr70
EXPIRES: 9'- 7/- '1'~
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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SIGNATURE
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DATE
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FOR OFFICE USE
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DATE OF APPLICATION: 5- 3./ f 0
RECEIPT II: D ), / 3 7 '<. ISSUED BY:
TOTAL AMOUNT COLLECTED: 1&. do
JOB'lI:
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