HomeMy WebLinkAboutPermit Plumbing 1995-7-17
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SPRINCFIELD
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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: 5576 C/acl<?r D....
" ASSESSORS MAP iI: l X" 0'- O~ II
O\INER: '~'e G;, i~lV\
ADDRESS: 5 oS 7 f:..' C-/O Gte=' Ir 0 v
CITY: ~r v-, ",,, 0, eJ ri STATE:
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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TAX LOT iI I (Jc6 va-
PHONE iI: 7'/6- ,yC)~'f
<91e.. ZIP: 9 ILl 7 r
CONTRACTOR: J e. V\ S<? '" ''Ct jo ~ \01 S +0 "
ADDRESS: \ ~ \ d. W Lv--<.. I ~ (,
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CITY:
PHONE iI:
STATE: ~
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9cr7-.J313
ZIP: '1 743 J
.~ONSTRUCTION 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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SIGNATURE ~
7-/1-'1s
DA'i'E
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FOR OFFICE USE
DATE OF APPLICATION: /- 1"7-15
RECEIPT iI: () I!? .3 .s / ISSUED BY:
TOTAL AMOUNT COLLECTED: I G . ~
JOB iI:q 5/1t(p
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