HomeMy WebLinkAboutPermit Plumbing 1990-4-25
J~
,.
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILOING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: '7b~1 (7/a (J(Y DriVL
Assessors Map #: Tax Lot #:
Owner: 1aI11lJlC, ~ t {};mrw-1" (f)//in5
Address:-7 IJ-37 (1/(lc(if ()-riLlL-
City: <fJr1(}c..fi{)tl State: az
Phone #:
ziP:Q7t.j 7 g
J
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ~dcL ~d-s~
Address: -5LffY I maJizWf eeL Phone #:
City: ~ ~0f./1L State: Af:-
.c,.,,.,C"+'''II-;+';^"l- 4:-:-...,J.-~..t~ J Regi-J.o:.-f-..! -- ~
~~ 'iJWJ~"~'~" .
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 .
1;,p;-Cf;;'/t,
Expires:
~~
Signature -
./, %~AA
J
'1/::J.5/fO
Uate
r ~,
FOR OFFICE USE
Issued By:
Ie:;, 15
Job #:
/IIlJliJlYIil
q()(j{;;D /
Date of Application:
, .
Receipt #:~Y3 J
Total Amount Collected:
l/ J)-5' /q/)
/