HomeMy WebLinkAboutPermit Plumbing 1997-6-21
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SPRINGFIELD ,I
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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JOB LOCATION: &-U.j fA/a.;/,I1/2t1/- f1c1 #;2 ~~ '1// .tJJl.
ASSESSORS MAP II: /'7032;)()lJ() 2'?-<<!rl TAX LOT II:
OYNER:_jr?r...4:nz/~ r-CJ#o"""'~""~'/ -SuJ-h. IJ)4/1fCf:t1J.C1 R~
ADDRESS: <6.6 < (.J.-2ed 'PHONE #: _ 'S ~J //175 fS'1 E I If/<. Ale
CITY: kfP;,{l - STATE: e>R, ZIP:97~ htL1/AA'.Oe...
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BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:~~'~ L({;~,,_JZ;a~L ,...
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ADDRESS: 'q~9;d /4-?C---&-A2-;" ,4/~7 PHONE #: ,
CITY: _Sn./4' STATE: ~ .zIP: ?7+"7'?r"
CONSTRUCTIO; CONTRACTORS REGISTRATION #: ~ b, 530 EXPlRES:.2 btts'/78
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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FOR OFFICE USE
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RECEIPT II: ;l. &1 if 7 ISSUED BY: \A./_
TOTAL AMOUNT COLLECTED:! (/) ,~~
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