HomeMy WebLinkAboutPermit Plumbing 1999-2-4
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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
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ASSESSORS MAP fi: \ 'I. () ).. n:s. \ 1 no ";1-KU TAX LOT fi:
OIINER: T,' __ P ~ fk~.~
;gENT, IQNf,,~~t>law re,g.U1res you. ~v
ADDR1ro; , .:k>l vthefOaagqnp!'!ilY s:h PHONE fi: 74-11- 9Z 50
T61 0\. ',~I~- nt Those rules a{e-SelfOIUI NOTICE: "
CIT~!l~:~~~~-~~.<tv.hm"~n OAR 952-001- STATE: 012,. _ n. .,_ ~.... I 'Zl',!Ip,: I/:'Tr.!ClI\\"!)RK
0090. You may obtai~~~\]Pi~~~~~::;~~~~ by ~~~:O~:;~~ ~~~-;R- THIS PERMIT IS NOT
BACKFkQl\1I,$l\lu'1,,1~r.~D t l'dNtlti(i~a~$ifATE SURCHARGE) + $.45 (ADMIN. FEE)"~o$16'r20R
numberlorthe Oregon I 'Y COMI"WNl;; U uH IS "o-:",~ ",~"" ~
CenteriU-BOO-;332-~344). ,." '_'" ~"p,~:")
CONTRACTOR: i:>v~< 1{4... :s L....l5~V< --I- r~V','),f."'~
ADDRESS:
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PHONE fi: rJ/.L/,- 7/'35
CITY:
STATE:
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ZIP: 97<1-7'1
EXPIRES: '-/-...7' In
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CONSTRUCTION CONTRACTORS REGISTRATION fi:
b 331:>
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIllS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE
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2../ <fir 1
DATE
FOR OFFICE USE
, DATE OF APPLICATION: ;)-4 ~Cj c;-
RECEIPT U: n.3 )..--;1< 7 ISSUED BY:
TOTAL AMOUN~ COLLECTED:, \t \ L? _ ;rLJ'"
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