HomeMy WebLinkAboutPermit Plumbing 1995-1-27
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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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JOB, LOCATION:~ ')S" JdJyCJALL {)j...
" AS~ESSORS MAP #: / 'i 03 ?. '7
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TAX LOT #:. /)4 ~crn
O\INER: " ".<.7f "'IV Uf,(J '-rAf,'
CITY:
H/a.!>Rce 0
STATE: OR..~
PHONE #: (.co~) (:, 'If) -r;r"<jv
ZIP:
ADDRESS: {U);H-, N W C1lf.AlllL RD.
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: RI(,1f7-wAY PJ.IJ.Mf!,fl1fh J. f!:,Ac..F)()t.() .5l'€VtC.L
ADDRESS: ~O I\r.~ "J/),)::Jb PHONE #:...:L8:.I,/-~,)k?
CITY: f...(J(~fNL STATE: t"JR..L ZIP:'11yCl/
CONSTRUCTION CONTRACTORS REGISTRATION #: ~-J9\ p, a EXPIRES: /'J,.-/b-9'{
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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SIGNATURE' I 1
I-:J./-')S
DATE
FOR OFFICE USE
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DATE OF APPLICATION:
1/27/'7r
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ISSUED BY:
JOB #: C)'c:oID(
.4P ;;;;r;
RECEIPT #:
TOTAL AMOUNT COLLECTED:
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