HomeMy WebLinkAboutPermit Plumbing 1996-3-12
.
.
"
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY-DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION: 1W Ut: .~1\J \JA-LE
'0)'<- ,
TAX LOT II: dq ~OO
..' ASSESSORS MAP II: II n3 ,::;)';1, 3.~
, OVNER: l( ~ l-rtt H-AN SON
ADDRESS: L.--\50 ' 6--1 ~P- tV VA- \ .e '
CITY: ~ f) & . STATE:
PHONE II: 'Id!
, .
Of...() ZIP:
9 'I q'j
" BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:. LV \ 10 s, uft 1..-f\JJO ~UtfJ~
ADDRESS: ,lIe) l.-A-l<:e O.r- ~HONE 1I:/igq-oCJ"2-1
CITY: ~U<::, - STATE: () Y -f ZIP: '17 4;04-
. -' /
CONSTRUCTION CONTRACTORS REGISTRATION II: :C) j '3 () EXPIRES: f 1:(- )( - <1 Cp
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.
~
?,---/J- - 90
DATE
SiGNATURE
, "
FOR OFFICE USE
--------------------------------------------------------------------------------
JOBlI:qw03i;(
f\Iv}p.k~' '
DATE OF APPLICATION~-/l-<i Lt
RECEIPT 1I:{J2f()(,p47 ISSUED BY: 0 -
TOTAL AHOUNT COLLECTE6Jt I ( V - /0
--------------------------------------------------------------------------------
""
F