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HomeMy WebLinkAboutPermit Plumbing 1995-1-17 . . SPRINGFIELD BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 * -------------------------------------------------------------------------------- JOli'LOCATION: ..3Lo?l H(nooJ Cl;) .Dri I R---, , ASSESSO~S l~P It: \'\O~~,,\\'L.J TAr.yT It: ffi~{) 1 OVNER: '0)\- ('li!1lp \ ~ ) (~01,) I no f1-i111~(]// , ADDRESS:,,~Ao~ 'rl)l 11\1-) PHONE It: 141' \f?5t. ~~- CITY: '00 ~cl STATE: ~ ZIP:-9:tl-71 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20 CONTRACTOR: ~\)Y\f\ \ cJ\\'N)\M- Q \nM~ LLhl1tQ~~ ADDRESS: -~ :H~NE It: l ~,.Afi. I~ CITY: STATE: CONSTRUCTION CONTRACTORS REGISTRATION It: !59-. VJ{l ZIP: EXPIRES:\.q 14. ~ 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. , ~I~E ~ ~ " //;7/9.r bATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: 1- /1- q::s '-- }, ,.., ;:- JOB It: q~ \ RECEIPT It: \\.pDO~ ISSUED BY:.(.4U. Lt ) TOTAL AMOUNT COLLECTED: II (). Q/j -------------------------------------------------------------------------------- , ,