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HomeMy WebLinkAboutPermit Plumbing 1996-2-26 ~..--- {I '.= .. 'I' ,." . . .~- " SPRINGFIELD " BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225'FIFTH STREET. OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 ------------------~::z-q-z;?7rd!iW~P--~-:..-d?e:;;?~- ';';;';;-,4).JF~-:;; /-h<:=~~ JOB LOCATION: (;~~~\\" c:;.,~n'4Le.lJ i tw . ASSESSORS MAP 1I: /?-b'1-?2-...c>t:::' TAX LOT 1I: ~ 2 2L:>?::> C,e..V\ua.1 C-ol"I\-raclor'1'..... . A \ '- ~: \ )l)l"""M.::u-- l :.0y\q....-ln) (l ~.i')V\ ADDRESS: 3 'LOt 9-.t" Q.MP~ ('...T)UX-~ PHONE It: CITY:-C ..f)'N.Jvrr.. STATE: ne ZIP:~ j\ BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20 CONTRACTOR: \\-(")i'C"I_~nY\ ~'5Cap.o, CO. ADDRESS: vJj, (JY)'i \ \Sh 7 _ PHONE It:M/o-(~L/ tJJ9 CITY:LlJ.c..JJf\O \ De... STATE: Oe- ZIP: 91d4o CONSTRUCTION CONTRACTORS REGISTRATION 1I: Lo~~' EXPIRES: \ \ 5"41.- 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. , k,.dA/J.J: {A )ali-PA S~N UR .- c2 -dto-9io DATE FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: --2-2C-c::::JC. RECEIPT 1I: 2c::JY~ ISSUED BY: TOTAL AMOUNT COLLECTED: /.6.7C> JOB 1I: Q5"'/ih97"'. ~~--- ~/. - --------------------------------------------------------------------------------