HomeMy WebLinkAboutPermit Plumbing 1996-1-12
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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:
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~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.
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PHONE ll: "--7L/ Ir {{Sf'S "5--
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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.
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DAT-t:
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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 -
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