HomeMy WebLinkAboutPermit Plumbing 1995-5-11
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ~.J.I"L'bi [\2Gyl1,M ~M' n:'-ifc:::O'X) I ~ af)~ ~
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ASSESSORf\MAP #: \t\ffi~~~ TAX LOT #:Jl)~
OlINER: ~\Jl . \b~
ADDRESS: ;-I') ~ ~ :\'~\Oc:l , ~Ct_]HONE #: es\~' \O~
CITY: ~ A STATE: ~~"--- ZIP: a-K-l<O
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
"I':~~~:~CTOR: ~\'\\~ ~~~t\ ~Q . .
ADDRESS: \) .(C) ~ \'1.AA- PHONE ~: \4'l.\~
" CITY:~C\.a N_ STATE: ~ ZIP:Ql3tT
\TRACrORS REGISTRAT ON #:~ EXPIRES: 4 .~C\..o
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BY SIGNING ,THIS PERMIT/APPLI ATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV 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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DATE
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FOR OFFICE USE
DATE OF APPLICATION: t\:.LL~ ; , . <J~#: q~(Ql1
RECEIPT #: V\~?F:> . ISSUED BY: c"1"\.~. I .
TOTAL AMOUNT COLLECTED: \\o.m -
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