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HomeMy WebLinkAboutPermit Plumbing 1994-7-11 .. .~ BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING. SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759, INSPECTION LINE: 726-3769 Job Location: :7~ y~ (J- <J!" ?~ - Assessors Map II: / ~Z:::_J;i" .. ~~ ~ax Lot U: I~/ ~~LP ,.,- -~ - v/J~~ <~ , ~ -- Owner: Address: Phone n: "'7 't"':> - ? / es-:r Zip: ~:> City: State: ~--( . Backflow Permit is $15.00 + $0.75 State Surcharge "':?~ t:f),~S" Contractor: ~ /.-'4";-:' ~~ .... _ ~..... it' Address: City: State: ,j . Construction Contractors Registration U: Phone U: Zip: Expires: By signing this permit/application, I agree to call for an inspection once the backflow prevention dev.ice has been installed and is visible for inspection ~:;~'I;t' th.t ,11 i"f",,""" thi' "P1i':"::;~ ~gnature Uate FOR OFFICE USE Total Amount Collected: '?--P/--9.~ Job U: c:5J 71 d!/ 5' c;..r Issued BY:~"",,,,,~ - //v ... 1~.:2'" . Date of Application: Receipt U: (?ti'~ .,