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