HomeMy WebLinkAboutPermit Plumbing 2001-12-14
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SPRINQFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DMSION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
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'( 802-0311
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Assessors Map #:
Tax Lot#:
01 9- O-c:::::,
Owner: Tov~ ,.... G,~-+~7
Address:
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Phone#: (;?, -0,/-0'
City: "50/,/, State: o~, Zip:97'1-7~
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BACKFLOW PERMIT 6 $51.7~~Udes Permit Fee, State Surcharge & Administrative Fee)
Contractor: -s;. J.. (. {s k, ~
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Address:
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Phone#: 74LJ.- 7 (<; "'5
City:
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State:
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Zip: Y 7'f"/
Construction, CoUtractors Registration#:
h330
, Expires: ~/-zr/o z...
By signing this perniit!application, I agree to call for an inspection once the backflow prevention device has
been installed and is visible for inspection (726-3769). I also state that all infonnation on this permit/application
is correct,
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Signature
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Date, ;,
FOR OFFICE USE
Date of Application: ' 12~ Cf ~I
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, Checked for Delinquencies:
Job#: 6/- 60 S-L( Z -er(
Checked for Historical Status:
VALIDATION: '
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