HomeMy WebLinkAboutPermit Plumbing 1996-2-21
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION:~3,~ GrAl~/ $-(_
.' ASSESSORS MAP II: J7~.eI'3':a<-<.O
O\INER: f.tv:\HZ- \IiL~ ht>TS
ADDRESS: ~C>~~ GtfI-eW~ 'S\'-
CITY: ~~~Q\e,,,~. STATE:
OFFICE: 726~3759
INSPECTION LINE: 726-3769
2~/ NCiI2th ~~ ~ \
TAX LOT II: .c7 '3~o C>
PHONE 1I:.1{2.0-g~rS'-"
t.)z, ZIP:~
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN.
CONTRACTOR: ~\\tJ\)bN D~5 :t1o~c>rJ
ADDRESS: ~OO ~lAI}\ ('i~f PHONE ~:
CITY: R:-v~ . - . .. - STATE: [12,
CONSTRUCTION C~NTRACTORS REGISTRATION II: l2..25'k
FEE) ~ $16.20
~ff-1l31
ZIP:j04<JZ-
EXPIRES: 1/ q ~
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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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FOR OFFICE USE
DATE OF APPLICATION: :2 -'Z/.9~
RECEIPT II: '2P C/5 S'
TOTAL AMOUNT COLLECTED:
ISSUED BY:
/-C .-:2... 6-
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2 <?-/-1,b
DATE
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JOB II : "7'6~"2 ~
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION
JOB LOCATION:3o~""3 Ga.WvJ~ <S-r.
.' ASSESSORS MAP !I: 1?-01'22...2~
OVNER: ~A::lrrL\I!U!r- Ai>t6
ADDRESS: 3<y?:;> (/)t1'~f2.\'v~ sr:.
CITY: ~()Pl~ STATE:
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FE~) = $16.20
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
40' Nou.t\ ()( t \3~
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TAX LOT 11: t!:J "3"::::;'O~
PHONE 11:
111
~20-~~qr
ZIP: o/l~~~
CONTRACTOR: \ti.DDEN k1Vtes ~O~A1ioV\1
ADDRESS: "S Lf ~lJ +lr.Wrh<.:"\.zNE'" PHONE 11:
CITY: €;V~ _ STATE: 0,
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CONSTRUCTION CONTRACTORS REGISTRATION !I: \t:~~
~-UJI
ZIP:JJ...~or
EXPIRES: 9-1 b
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. .
QIJ~ ~8~~
SIGNATURE . . .
FOR OFFICE USE
DATE OF APPLICATION: '2-:::? /- %
RECEIPT !I: ~5"l.f ISSUED BY:
TOTAL AMOUNT COLLECTED:
/&~ :2-
2>21-f6
DATE
JOB .~:~~~
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