HomeMy WebLinkAboutPermit Plumbing 1994-8-2
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING, SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: 10 f..J-1b ~ AJ c1{7)ul~j/L' W
Assesso~ 0: lID?; &L.'"3J Ii Tax Lot 0:
Owner: "i~ \ -/A.:0\N1_
Address: (115 J).eb Y1 eX- {2.J
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Phone 0:
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Zip: 97l(o J
City:
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State: {)(L-
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Backflow Permit is $15.00 + $0.75 State Surcharge ~:3~
Contractor: p.~VZJJJ 1 Ji-1A J ~'> CQpe-.
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Address :7L/ <i{<;f I
City: ~/lA~ State:
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Construction Contractors Registration 0:
Phone 0:
7 t.{ 7 - "37' L{ (~
Zip: Cf7t.(oC;
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention dev,ic,e has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
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Sign~e
FOR OFFICE USE
Date of Application:
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Receipt 0:
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Issued By:
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Job 0: Cfc{oZ-22-
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Total Amount Collected: