HomeMy WebLinkAboutPermit Plumbing 1998-3-31
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t-lO' EXPIRE lfi
1\-11S pERMIi S\-IAL~R 1\-11S pERMIi \S NOl
A\.rr\-lORIZEO UNO e^NOONEO fOR. . .
EO ORIS A "
COMMENC ~~~FLOY PREVENTIO~ DEVICE PERMIT APPLICATION
AN'I1800"V p,,' CITY OF SPRINGFIELD .
BUILDING SAFETY DIVISION
SPRI.IELD . I . ~. -~
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726..3769
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JOB LOCATION: :>(0 /~U/-""r1t~.
. ASSESSORS MAP ti: /7 O.s d ~ 7 S
OYNER: d~ S'~..a~
ADDRESS: S a --67 A..-Lb>,nJ oJ?; -
CITY: _\' ,'2'..~-~4~ STATE:
-/~~7' .
BACKFL0Y PERMIT IS $15,00 + $,75 (STATE SURCHARGE) + $,45 (ADMIN. FEE) = $16.20
TAX LOT ti: g:300
PHONE ti:? Yt" ~b61
rA ZIP:
CONTRACTOR:
(JdJ f?~~'
_'1 '? 't ? /,., .bn."", Lc..c. /42
PHONE ti: 1 't [, ~ }' f'--6
ADDRESS:
CITY: E:-L~"';" STATE: Ol?
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CONSTRUCTION CONTRACTORS REGISTRATION ti: (~') '6'-1
ZIP: 9?ytrs-
EXPIRES: r ~3J- 9- ~
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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SIG~TU;~ - -
:J ~ .J' / 9,p-
DATE
FOR OFFICE USE
DATE OF APPLICATION: 3~3/'" q~
JOB tI:qg()~ro
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RECEIPT ti: ISSUED BY:
TOTAL AMOUNT COLLECTED::1> \ l() JJO