HomeMy WebLinkAboutPermit Plumbing 1994-12-28
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SPRINGFIELD
BACKFLOY 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: 2?o b Lr-lM"",/j <+ i < "55? &e:::::::#.
. ASSESSORS MAP #: L.e::.r //8 -_ ~)"2:>N- ~ ~TAX LOT #:
OImER: +11i ,-1 -z: Can", /.
ADDRESS: 'frL-//~q /:2""1......." J2~/ PHONE #: . 7~6- ~ 7<87
CITY: /J /C/.> c:~_-k //1/ / STATE: oR. ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: ~L J /:s ~"uIC/,p~.,j 7/;.60./!:' . .-::z:;;" .
ADDRESS: .t-/:6GCirCJ ~C-A;"%'N: ..tL.-,/ PHONE #: 7qG~ 7/.?S'
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CITY: G/Y STATE: ("J.P. ZIP: <J7L.y 7<7f
CONSTRUCTION CONTRACTORS REGISTRATION #: /;;( / 7C) EXPIRES: o..-h / 9 ~
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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
FOR OFFICE USE
DATE OF APPLICATION: /2-28.'-'C/
RECEIPT #: /"S"85Y ISSUED BY:
TOTAL AMOUNT COLLECTED: ;I.'~. ~~
JOB #:
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