HomeMy WebLinkAboutPermit Plumbing 1997-6-23
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SPRINGFIELD'
BACKFLOV PREVENTIO~ 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: ,~.'l.~.'l 6-0 Ie Wet 1/
" ASSESSORS MAP lI: / 70?' / S 006
OIlNER: ioe Tn /<0 i Iv 1re m Ie r
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ADDRESS: S:))-')- (r-;' f-f' lua v
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CITY: ,\1711715 f,f lei
TAX LOT lI:
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PHONE lI:
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ZIP:-!12.'1J 7
STATE: (I') If
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: Em eY'o /ri L II-nd.<::ca 0('
ADDRESS: 'Ir(}.rJ<!t. AI 1-/,/1/111'/1/ (),
CITY: Cres VJf' 1/
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PHONE lI:
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ZIP: 97'1;<(.,
STATE: (J;(
CONSTRUCTION CONTRACTORS REGISTRATION lI: t,:'l r /
EXPIRES: f? - '? / - 9 7
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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DATE
, FOR OFFICE USE
------------------------7-----------------------------~------------------------
,DATE OF APPLICATION: (0 12>/o;r, 'JOBlI: 1(;)/079
RECEIPT lI: ()2(P2'/L(. ISSUED BY: :t. II//I/~ '
TOTAL AMOUNT COLLECTED: 1; / & . 2-0
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