HomeMy WebLinkAboutPermit Plumbing 1995-12-21
[I
"
.
.
BACKFLOW 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: GaLl:)
ASSESSORS MAP It: \~tr--~()
OIlNER: lJ)-C:-:7 f=id-'tJ t--l,K.
ADDRESS: 3:T'IS- &mbW~
CITY: r....J '(""',<.1 CTFi EZ-O (STATE:
( 71f7-Elihtfj
TAX LOT It:
.
OC) \f} \
PHONE It:
DK,
ZIP: Cf>(77
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CO~Rl\CTOR: rer,jl" cf: /1te""
ADDRESS: If fie /-e ;<.(}t9!-0"\ fiue
CITY: C iL 'f <Jv...f'
PHONE It:
7L(! - (() CJ 1.6
ZIP: 17-'("07
EXPIRES: t ! }' 0/ ~
I .
I
STATE: Cl (\
I J.J ;>0
CONSTRUCTION CONTRACTORS REGISTRATION It:
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). 'A"O ~~"' "'ORHA"O' 0' "" "","/A""""O' "
CORRECT. .
- y~ dJ p(?C cr5
SIG~ATURE ~. DATE
FOR OFFICE USE
::::~::::;:~~;~r:~?\:~:()~.;~~:::~~~~~;::~::~orol[r
TOTAL AMOUNT COLLECTED: \ rl()
--------------------------------------------------------------------------------