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HomeMy WebLinkAboutPermit Plumbing 1996-1-12 -- . SPRINGFIELD BACKPLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY-DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 JOB LOCATION:1?- gc; a/de /-e- .,R..- .' ASSESSORS MAP,!: \~ll7rQ_YL OIlNER: . JJ11 t:c ::: 7A f-,t::. ADDRESS: z:).29 GI.4cJe rz. CITY: -5 f?f&-)~'~/A STATE: ~ ~AX LOT ll:~) PHONE ll: '7~.-OoD9 (){Z. ZIP:_q7~/-17 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: c::;, ~".J) , [,.;6 1\.JdfZ;4f~ ADDRESS: P?J. ~x-- -:)...~ / CITY: .s p ~j r--8,..- /fe Id CONSTRUCTION CONTRACTORS REGISTRATION ll: STATE: oe. 5s/5-- PHONE ll: "--7L/ Ir {{Sf'S "5-- ,. ZIP: CJ'7U7 I EXPIRES: //J/q? 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. ''''^~~.. D/;rL\ Ij/:;v DAT-t: " FOR OFFICE USE DATE OF APPLICATIO~: \ . \ 2 q~ J. \ ,.)JOBll: .~\d;:Drcn RECEIPT ll: ~\t'k) L; ISSUED BY: (_) iflC\ TOTAL AMOUNT COLLECTED: \ \(l ,I)jj - . ole "'"