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HomeMy WebLinkAboutPermit Plumbing 1996-5-3 ~ ,---.:. 1(\ 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 " -------------------------------------------------------------------------------- JOB LOCATION: '2()qf . C(~GVL(""";C luUf, \ 1 8''5 2..2- 4- 3. (c, (,u;;- ~ j1L~'1 (7",-:(~ ~ /J1,T &If ?b A-O 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 ~ffftr'l/f- (c,,,-dfc '1~~ CONTRACTOR: ADDRESS: \D'LD lr-el{ IlL PHONE II: CITY: 0l-1\1 '\",r/"'t"(cl STATE: oe, ~ ' CONSTRUCTION CONTRACTORS REGISTRATION II: i (~( C( "1y~- IOJ 5" 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. ~~ SIGNATURE li --- )- '7C:> DATE .. FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 5- 3./ f 0 RECEIPT II: D ), / 3 7 '<. ISSUED BY: TOTAL AMOUNT COLLECTED: 1&. do JOB'lI: /7. !nQJeh,,)-7.n q if/ Ii/I -------------------------------------------------------------------------------- ''''' r