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HomeMy WebLinkAboutPermit Plumbing 1998-4-27 . ~ e SPRINGFIELD .1 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: 5()ql \5<( TAX LOT #:~(() . ASSESSORS MAP #: OVNER: . p, I II R PERt; U.C:/JN' ADDRESS: 51? OJ F,o/?,c:;yTHiA DR CITY: E PR INt: ~;ELJ) STATE: . PHONE #: 7Lt7- q73/? n R ZIP: q 7471 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: -..S A MJ: - A ,<; )I b J:) v 1I"\r: 1AI0P.\I. "'IO"'{\Ct.~ c"'I'\P.~ fr \., ~IOi ADDRESS: I' _ _....~1I,. S~~ll -'/<' rCQlJ.1'T \S" PHONE #: 'nolI\) r"" . !'IOcR \ fl'''' - EOP. CITY: ,L....1ol0P.I'lEOU t' 'Qll.NOO!'l~AT1:: ZIP: r-"" OUl'\.",r. CONSTRUCTION CONT~~~~~ION #:, EXPIRES: ~'\aao~ '. \., 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. ' . '(8.11 (]3 SIGNATURE ~~n & fe-27-q~ DA FOR OFFICE USE ---------------------------------------------------~----------------7\---------- DATE OF APPLICATION: 4;:27- 9~ JOB #Q~LJ4~l RECEIPT #: !;(\n~) ISSUED BY: n . fYlf)(lJrfY,/{'\ TOTAL AMOUNT COL~ECT~D: l J/ / &, dO