HomeMy WebLinkAboutPermit Plumbing 1995-7-24
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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
JOB LOCATION: 5712.. ~rphA.
, ASSESSORS MAP 1I: / ~ /"} 2.- d 1- / /
OIINER: Je:r-7Jcs //hi!.
ADDRESS?t J'~2. .l, 5"1'b ~ 5 r
TAX LOT 1I: A O/2-c::>
CITY:
~~
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STATE:
PHONE 1I: 7~7- J 17.J
~ . ZIP:. 5' 7~9:!t,
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
C>tt),V~
ADDRESS:
PHONE 1I:
CITY:
STATE:
ZIP:
.~ONSTRUCTION CONTRACTORS REGISTRATION 1I:
EXPIRES:
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. .
;04~,r
DATE' '(.
FOR OFFICE USE
DATE OF APPLICATION:~~~~~~
RECEIPT 1I: /fb424 ISSUED BY:
TOTAL AMOUNT COLLECTED: J {;. ?..O
JOB 1I: 9+, 1/70
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