HomeMy WebLinkAboutPermit Plumbing 1996-2-16
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BACKFLOV 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: "2 5"~~ c;;,A7't5U/~9.
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OVNER:-L"~t:F7 ~T/:h~
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ADDRESS:--:?~S 6~U/Ar
CITY: ~..z>~p_ STATE:
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TAX LOT 1I: ~ ::?:z~
PHONE 1I: -=?,s/~~::?g~)
~A . ZIP:. 97Y7?
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: i3/~~ ~~ T.?"~~~
ADDRESS: "?t:?, 757Y ":.:b 526 PHONE lI:,
CITY: E~F~/c- STATE:~~ .
CONSTRUCTION CONTRACTORS REGISTRATION 1I: tr'9 % /
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ZIP: ""'3'?~ /'
EXPIRES: /..? -::C~
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
CORRE '
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DATE
SIGNATURE
FOR OFFICE USE
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DATE OF APPLICATION: '2~-~ JOB~:~~~
RECEIPT 1I: Z.o'T/'?J. ISSUED BY: /2~. "
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TOTAL AMOUNT COLLECTED: /h.2C)
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