Loading...
HomeMy WebLinkAboutPermit Plumbing 1999-4-5 -. .~- BPRINC FIELD , ..lA.~ ": tu .~ - BACKFLOI/ PREVENTION DEVICE PERMIT APPLICATI0:: CITY OF SPRINGFIELD BUILDING SAFETY DIVISION ~ OFFICE: 726-3759 INSPECTlt:l LINE: 726..3769 225 FIFTH STREET SPRINGFIE::.D OR 97477 -------:---------,"':--------------------..------- ----------------- - -. ----- ----- - .. ----- JOB LOCATION: j'?7 1J'/'<</5"e ~C7y ", TAX LOT j!. q / 0 A.iTE:N'~ 'n"" ION."... No .'.-rvrUleSad n:&Vf1/~J~' d/ <<--'I/n ,!,/~/:ation Gl'H8NEtC!t.tiY)1'i;r r7-"~erl JZIf/J /0090 I, ~';92'00;:~";' Those rUle :lJun UtiJi/<u. . STATE: '\O<r,n",,", lOthrau"" ~s'7JI'R:9"M~.'f7' 7 7 -""lf1g th - --'am Co . ~R 952 ... . nUfT1be ' e Center (N Pies of the '001.. r lOr th . ote' th rUles" BACKFLOI/ PERMIT IS $15.00 + $.75 (STATE SURCIIARGJDlt+es74"l!7c~I\91:.,.N~tfFJij,)~,r. ~lI.6.20 . er,s 1.ao litYNon' e . L7 0'332'2344) IICation C;ONTRApTO!'j: ~7 r~a/n~I'~'1?, Zr?c:.. . . . , " ADDRESS: A:? /3 C7 Y 2 / .r7 PIIONE #: y /'5'"- () 55? ... CITY:1R~~# L STATE: t:Pr ZIP:f?7f'~Z. CONSTRUCTION CONTRACTORS REGISTRATION .: Lf / 'ff'a)"5::r.. EXPIRES: If -0-0.' . I ~Q~/ISH. BY SIGNING THIS PERMIT/APPLICATION,t I AGREE TO CALL FOR,AN ~Nd!'.E<n'.ION ONCE TilE BACKFLOI/ PREVENTION DEVICE liAS BEEN INSTALLED AND IS VlsiiitE"i"OR 'fNs'PEC'l'ION (726-3769). I ALSO STATE THAT ALL INFORMATION.,P~. TillS PERMIT. ,~pp.t'I.9~~t'9N"''i:sr:( CORRECT. c<':..,.. r'/::;" liP/DON.' liS i.'or ,.,mu. 'ED FOR /7r'Js ))2f)D OI/NER::O~nP1l.../ 5 ADDRESS: . .j'8'7 /(r~u '5e.. .- - CITY: ~p r/./~ ,{:,;.e /d / " ASSESSORS MAP #: ~..,#" ~//p-~ :>.!.GNATUIU. /' or r ~-~-.97 "".", L1''- ~ FOR OFFICE USE '," ::~:-::-:;::::::~:::~--lJ/~7qq-------------,--~--------:::l ~~-qqD;;~q RECEIPT h, D<<2 ~q' ISSUED BY: Y1. /IJ1~ ~ TOTAL AMOUNT COLLECTED: 1; /{O.~O -------_.._----------------------------":"---------------------- - -----------.. ------