HomeMy WebLinkAboutPermit Plumbing 1996-2-27
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, SPRINGFIELD
BACKFLOY 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: /, 9b?-- GlAcie J?-
" ASSESSORS MAP 1I: /~-o"2~"2...-2 3
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Oi1NER: ::J ~ /I!'-€--':; \.hVNIY'
ADDRESS: c:;. 9 0;;2.. ~ I ~!:Z ?
CITY: SPPN.b:t1e:a
TAX LOT 1I: /~~
STATE:
PHONE 1I: 71/ L - 571 '3
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/)12. ZIP: 1'7 {j-17
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: G.,e.-,AqJ)C:; ~A..r-I0JJR7 ~/Jce.~
ADDRESS: .f!a &':>0 ~?-/ / PHONE 1I:
CITY: <P~/~<I1elrl STATE: OR
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CONSTRUCTION CONTRACTORS REGISTRATION 1I: ":5:y..:2-
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ZIP: vC/77
EXPIRES: /q/9k>
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. '
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FOR OFFICE USE
RECEIPT #: -:2L7$':<~
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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DATE OF APPLICATION: 2-:2'/~
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