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HomeMy WebLinkAboutPermit Plumbing 1996-2-27 Je e- - -, '~--., , 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 ,---- 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 - - /)12. ZIP: 1'7 {j-17 BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: G.,e.-,AqJ)C:; ~A..r-I0JJR7 ~/Jce.~ ADDRESS: .f!a &':>0 ~?-/ / PHONE 1I: CITY: <P~/~<I1elrl STATE: OR - - CONSTRUCTION CONTRACTORS REGISTRATION 1I: ":5:y..:2- '7 i/t ?(Lj<t~ ZIP: vC/77 EXPIRES: /q/9k> BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. ' - (ij~ I>~ 7URE / ,ZJ ' ~/::J-7 /rr: .. FOR OFFICE USE RECEIPT #: -:2L7$':<~ TOTAL AMOUNT COLLECTED: ISSUED BY: // }OBII:~6"c:t:>:z~ cy ~J~~ DATE OF APPLICATION: 2-:2'/~ /b'?~ -------------------------------------------------------------------------------- '"