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HomeMy WebLinkAboutPermit Plumbing 1995-10-4 . ., SPRINGFIELD BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING ,SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: Y-9A:> &R5'?T#~.4 A , ASSESSORS MAP 1I: /A'-cr< ~t:/-d(? TAX LOT 1I: ~2<3:;.-c;...> OIINER: 'Z?~ ~~/? ~~ ... / ,} - . .'.... . - &' ADDRESS: PHONE 1I: CITY: STATE: ZIP: BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR:Z/YV/~4~r..4C t;-f?~~~r!r /./.~~C~~~ ADDRESS: h// .#~ ?c?~~,. PHONE 1I: '?c;.':) - ;g~< ~ CITY: ~ STATE: ~ . ZIP: ~V;:>s. ~. / - ' . CONSTRUCTION CONTRACTORS REGISTRATION II: S~ ? EXPIRES: 5'-3,.. "7~ //:Is~ \ BY SIGNING THIS PERMIT/APPLICATION, 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. ' t/ FOR OFFICE USE " -------------------------------------------------------------------------------- DATE OF APPLICATION: tJ.--.r ~ '?s , r RECEIPT 1I: /9/90::;;::: ISSUED BY: TOTAL AMOUNT COLLECTED: /6. ::2e::> JOB 1I: 95'~/YS- 4~' --------------------------------------------------------------------------------