HomeMy WebLinkAboutPermit Plumbing 2001-11-1
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SPRINQFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DMSION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Assessors Map #: ./70 J z 7 (0
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Address: I q 1'1 k '^-Ir '"
Job Location:
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TaxLot#: D3200
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Phone#: I L{ ( - 8 Lf~ ()
Owner:
City: 5 fFd State: ct7r=.... Zip: . Ct., t..( 1 1
BACKFLOW PERMIT I~c1udes Pennit Fee, State Surcharge & Administrative Fee)
Contractor: Oc.6 ,., . '1.. ~ V (' ( _',
Address: (,?.to S\A ""'~v ~
City: 'C..v--, <- State: C5 ((. (
Construction Contractors Registration#: 5'( f { . Expires:
Phone#:
Zip: ql L( q l.-(
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By signing this pennit/application, I agree to call for an inspection once the backflow prevention device has
been installed and is visible for inspection (726-3769): I also state that all information on this permit/application
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Signature r
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Date.
FOR OFFICE USE
Date of Application: / / () 10 (
Job #:. 0/ -0 /21 '7 - 0 (
. Checked for Delinquencies:
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Checked for Historical Status:
VALIDATION: .
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