HomeMy WebLinkAboutPermit Plumbing 1994-5-2
.'
.
.-
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING, SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: ~B~tC-. ~'{,~(',.-,,=,~ ~-
Assessors Map H: /25'-'::::><~c:!:><-<"'<.... Tax Lot H: ~~~
Owner: #'~/~ 6:/?:?~~ ",
Address: 7'~O ,N ~ ~~ ~ Phone #: ?~~ ~'7y
City: ~~CD State:~. Zip: q'?C//8
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
~~~.~
Address:
City: State:
,j ,
Construction Contractors Registration #:
Phone II:
Zip:
Expires:
By signing this permit/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 information on this application/permit is
correct.
/~ /' -- '"
Signature; ( 7
,,,C_
,
5'-Z.'-9<f
Uate
FOR OFFICE USE
Date of Application: 0"2--~.Y
Receipt II: /25':)/ Issued By:
Total Amount Collected: /~ 7.':;-
Job #: 4~~~2..
~~~.
//