HomeMy WebLinkAboutPermit Plumbing 1996-6-28
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BACKFLOV PREVENTION 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:
1-/5(05 +\-at\. S+
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'iAX LOT II: nv. ~()( )
. ASSESSORS MAP II:
OIINER: 'i'SWJ. H' A'\. .~p '.oD.I' l' IX "- ~ O~ ~ l ttflA
ADDRESS: L\. ~loS ~LL ~-,l
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CITY: <;;::pYl~G.M
BACKFLOV PERMIT IS $15.0~75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: \~~, )~\O t )
PHONE II:
1 LIl-31d.-B
ZIP: C\ 11..\.18'(,,(,,'17
STATE: Ov:..
ADDRESS:
CITY:
PHONE II:
STATE:
ZIP:
CONSTRUCTION CONTRACTORS REGISTRATION II:
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,
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DATE
FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
. 9i.o t;;i J;" ^ JOB II: .Q1{)B0JQ.
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RECEIPT II:
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