HomeMy WebLinkAboutPermit Plumbing 1995-4-24
.
e---..
",l-.'
",.
\
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: -:?3 YS- L&>c:.R' ?>:c:-. '
L-,r -<- ~~;;:;Y J-->>"~
, ASSESSORS MAP #: .TAX LOT #:
O\INER:,~71/f/c:.4';- 5/~Cr:;..I~/
ADDRESS: 2.':Jtr? ~ ~. PHONE #:
CITY: ?~z;> STATE: ~.
"
?$I/-<-<......:'g
ZIP: q~ //
BACKFLOY PERMIT IS $15,00 + $.75 (STATE SURCHARGE) + $,45 (ADMIN. FEE) ~ $16.20
CONTRACTOR:
~~~~
.' .
ADDRESS:
CITY:
PHONE #:
STATE:
/
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION #:
EXPIRES:
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,
. ,
~ &) ,td.:.A:-
7'-? y- 1.;-
DATE
FOR OFFICE USE
DATE OF APPLICATION: l/- 2~ ~7-
RECEIPT #: l~9.5it ISSUED BY:
TOTAL AMOUNT COLLECTED: /'~_ ~~
{
JOB #: ~"5""'~/
a---- - -
r //v -
--
--------------------------------------------------------------------------------
~\