HomeMy WebLinkAboutPermit Plumbing 1996-5-28
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:
~ 2-57 L &Yz-A f'<J-...
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AD
Vr~+f\- D2
TAX LOT 1I: nC-Ot'l (17
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.' ASSESSORS MAP 1I: l 7 03
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ADDRESS: -Z S 7 l... ~.......\o.)
CITY: Sor-i\o.c.f'f.. 1~
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PHONE 1I:
STATE:
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ZIP: 97't77 '
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) +'$.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: ~ ~ \( k",l s ".....~ c;,...~,..~ +.~.. L l c.
ADDRESS: !P.o. 30\ 'F7
CITY: W "ht...." t lk STATE: ()~
CONSTRUCTION CONTRACTORS REGISTRATION 1I: (, 81 V
PHONE 1I: allko'? t> I
ZIP: '1'71/8'1
EXPIRES: $/<17
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.
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S,rGNATURE ,/ Q
5/ZSl1t
DATE
FOR OFFICE USE
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DATE OF APPLICATION: ,t::; J }f/) q u JOB 1I: 0 (/J (') 7 f I
RECEIPT 1I: .;JIII? 74 . ISSUED BY: V1. /Y"\ot"htJ d.o
TOTAL AMOUNT CO:r.EC~ED;'~ If{l.-:YO
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