HomeMy WebLinkAboutPermit Plumbing 1995-8-9
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BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION,
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
ADDRESS: \o"1() \.. ~Q l C"\- ^ PHONE It:
CITY: \ 'J\ ~ l:\\ l\~ Q , STATE: ~
Q~.2x~3L
ZIP:~
BACKFLOV PERMIT IS $15.~TATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: \ \ u J~ QJ~ ~
ADDRESS:
PHONE It:
CITY:
STATE:
ZIP:
.~ONSTRUCTION CONTRACTORS REGISTRATION It:
EXPIRES:
BY SIGNING THIS PERMITIAPPLICATION, 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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SIGNATURE I
f( -- f~ Cf<
DATE ' ,
FOR OFFICE USE
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DATE OF APPLICATION: [3.q ,C(c:; \ 1 \ ' JOr~: <1 ~rYL<6lr2
RECEIPT II: \ ~\{J~O\ llo. .:S~D BY:' ("J \\ D!:'L/
TOTAL AMOUNT COLLECTED: ~
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