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HomeMy WebLinkAboutPermit Plumbing 1995-5-11 / Ties ~ ".: __. .-' .:., i~:: SPRINGFIELD BACKFLOY 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: &,903, Fors''-'1ft'Ft- v ASSESSORS MAP 1I: /6"O~ .c>~~Cit<. OYNER: 5~ h~ 1 Qp.~he,'I( 5Df.},,Af,'e. (J 97tf.l) 9, J TAX LOT 1I: ~3 y~ " ADDRESS: CITY: (g 9 n <. F ,)( 5,,) +t..it- 'S Dr M '<'" fteU I V STATE: PHONE 1I: of<.. 7:) ro - '" (:l-S:- ZIP: '171..(7)( BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20 CONTRACTOR: /)A.J-rt)J..)y 6t-uXs. . . ADDRESS: J7 ~<:" cl "'A-r-LAlt-!-e-<- CITY: C, ~/L(nJC,/~ /d " v CONSTRUCTION CONTRACTORS REGISTRATION 1I: DR- {~ 't'a ~ ::;- / ;}CIQ (0 BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. STATE: lYle,.rd'cJ(..J l,A-,....d'c~ SerGk-'d S " PHONE 1I: 7;) (,- 770 ~ ZIP: 97 Lf7 g EXPIRES: LJ/?U/lro / , ~..// ~ _ Qau.P- SI,"A~ S--I;- rS- DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: , "S-//"''9~ ~ JOB 1I:~CE;/~ RECEIPT 1I: 17~~5" ' ISSUED BY: '/.r~ . . // TOTAL AMOUNT COLLECTED: /6- 2~ / --------------------------------------------------------------------------------