HomeMy WebLinkAboutPermit Plumbing 1999-3-1
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SPRINGPIELD
BACKFLOV PREVENTION DEVICE PERHIT APPLICATION
CITY OF SPRINGFIELD
ATTENTION:Oregon law requires \lJU~bDING SAPETY DIVISION ' ,
f 1I0w rules adopted by the Oregon Utility
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c~i J.llA lie~te. N tj!;, the tele~Ro~e ~,l r-, , , ~ ~UT,HORIA') UNDER THIS PERMIT IS NOT
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.' ASSESSORCSe"WPi1tSpOnH -~ 7 G-J I () 0 } rn.:J ANY 1TAX 'LOTEli:Jr
OIINER: .; Uu d
ADDRESS: .:::; A J-Y1 E.
CITY: 5 p r/Nr+'u:.Jd
.PHONE 1I:
STATE: ([) ~ ,
ZIP:
BACKFLOV PERHIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN. FEE) a $16.20
. . ~ONTRllpOl';: S. C ,T .p / !A- m h (/(/ f -of 1-)614-7: AI ~ ,
' ADDRESS: P. 0 I Rt<?x !!59 t PHONE II: 0/3 S - .;( / S (,'J
CITy:-1J.f..#-F;t;; STATE: rOr-E ZIP: 97C/f? 7
CONSTRUCTION CONTRACTORS REGISTRATION 1I: /33 I {If 7 EXPIRES: /&-/ - '19
BY SIGNING THIS PERHIT/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 INFORHATION ON THIS PERHIT/APPLICATION IS
CORRECT.
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3-1-99
DA1'E
FOR OFFICE USE
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DATE OF I;PPLICATION~-I-~ '1
RECEIPT I': (j.5 lq q Y ISSUED BY:
TOTAL AMOUNT COLLECTED: \ It 1(/. -nJ
JOB U:C)7/7/'/-
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