HomeMy WebLinkAboutPermit Plumbing 1995-10-11
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BACKPLOV PREVENTION DEVICE PERMIT APPLICATION
CITY Of SPRINGPIELD
BUILDING .SAFETY DIVISION
225,PIPTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 0 J 2- L I /JlJ -cY' lr.a. F
" ASSESSORS MAP #: I, 0 ~ ;;)::L '-I:+-
O\lNER: tA'/?E J/uO/V7A/lI
ADDRESS: hl7 ..; /,?{/cr' ./_"'..{: ,?tJ
CITY:~)1;-~J STATE:
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TAX LOT #:. 07 (J7TO
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PHONE #:.
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ZIP: 97'7?7
BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:I)rt-,Fl L-AN/)'leJI.lr:
ADDRESS: <2 t( ~ /J,j
CITY:. EUj-r-nc
CONSTRUCTION CONTRACTORS REGISTRATION #:
PHONE #:
STATE: ~L
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ZIP: 9?'?tf'/ Y
EXPIRES: JZ- 3'/- 7'5
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLO\l 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 I
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DATE
FOR OFFICE USE
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DATE OF APPLICATION: / () - II - 95
RECEIPT #: () / 9;;;.25' ~ ISSUED BY:
TOTAL AMOUNT COLLE E ) &. ')-0
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JOB ji:
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95cJ 77'/
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