HomeMy WebLinkAboutPermit Plumbing 1994-8-15
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING .SAFETY DIVISION
Z25 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ~ &r?~pJ~ - "'-::::;.e~Fr::::z.-..=> c::1P '
.' ASSESSORS MAP ll: \1D3~()) / TAX LOT ll:--DmOf..o.-
O\INER: '17~~, 4-- ~ ~~-S
ADDRESS: ;;2-''54& ~"f'3rb-.. PHONE ll:
CITY:~I--. "",,..-j~
STATE: ~
ZIP:
BACKFLOV PERMIT IS $15,00 + $,75 (SlATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR~~ce:- ~_ ~~"...:~ ~~~ON
ADDRESS: \q40 ~\~/....,?-= '\'},. PHONE ll: ~h.i1i;;7
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CITY:J::::UZ~ STATE: ~ ZIP:q{~
CONSTRUCTION CONTRACTORS REGISTRATION ll: (0;;(4-5 EXPIRES:
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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FOR OFFICE USE
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TOTAL AMOUNT COLLECTED: 1 \(J.W -
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