HomeMy WebLinkAboutPermit Plumbing 1995-7-17 v . - . . SPRINCFIELD .' BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- 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 Spv. "<1 0-H? IJ ge. '7/'1 7r I 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 ~ (, ~ \"'~. ' CITY: PHONE iI: STATE: ~ O()({,6s9 C; , 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. . rrn.~ >>0~ SIGNATURE ~ 7-/1-'1s DA'i'E , 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 --------------------------------------------------------------------------------