HomeMy WebLinkAboutPermit Plumbing 1995-1-17
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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
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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.
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//;7/9.r
bATE
FOR OFFICE USE
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DATE OF APPLICATION: 1- /1- q::s '-- }, ,.., ;:- JOB It: q~ \
RECEIPT It: \\.pDO~ ISSUED BY:.(.4U. Lt )
TOTAL AMOUNT COLLECTED: II (). Q/j
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