HomeMy WebLinkAboutPermit Plumbing 1999-3-5
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 FIFTH STREET
SPRINGFIE::,D OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726..3769
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JOB LOCATION: \'6~~ \.il.WI.D--. s,D.c\cl, DR 0,471
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O\INER:J:3.~',-~I-\.. u.n 1..f.f ~ (JJ (iah+--: ATTEN1;ION:Oregon law requires you to
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ADDRESS:": \<& ~ ~ I fUU--o.. _ V . Notific'PiwNg;€1I'!er~~~ ruhPiEPr$~t forth
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CITY': ~Yl'~i::j 1'3!i.rr~ilt fin: "f'-I;.'; STATE: ()~f.1.v'(ou may obtain cOZ!a?,:oHfie-tlilils by"
,',,' J', '.,' 'I'W ;.,'. " ""JT \!lallmg tne center. (Note: the telephone .
'. . '" " . " . number for the Oregon Utility Notification
BACKF!.OV' PERMIT ISr"$l:5'fOOJ -I'C$1. 75 (STATE SURCHARGE) + $ .~~,t(A"HlIN~OF"'E>\2~,N6. 20
}-\I~Y 180 DA" PERiOO. ' .. ,'" -" -"""" v 'I.
CONTRA,C'rOl'j: hn VII Q" l1loh Ie c...h P ll.l.mbir'1C1 I hi
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ADDRESS: 2 ('61 ()\ LjI-vLD If ) -*;;n
CITY:S,,,'vi ~_e.Acl. STATE: oR...-
CONSTRUCTION CONTRACTORS REGISTRATION I: (~~~:) I \
PHONE 1l"L.{O' Ci'6SLf
ZIP: C)7Li7l
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.
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SIGNATURb 0
3J-?" QCf
DATE
FOR OFFICE USE
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DATE OF J;PPLICATION:3f:s) q q
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RECEIPT h ISSUED BY:
TOTAL AMOUNT COLLECTE~ I to . '60
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