HomeMy WebLinkAboutPermit Plumbing 1999-8-17
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SPRINGFIELD
BACKFLOW 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:
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ASSESSORS MAP #: / Y () ;r 0 ~ d- J
. OWNER: )?tAd J(- ;{;g;.s;, '"
ADDRESS: /236 tiA~/~)/?
CITY:_ ~.;... -t~LJ ":':,"
TAX LOT #: ()..}.~
PHONE #: '?3h'- t;3"l:2.
STATE: ,,;1'. ZIP: 9'7</1> 7
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BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN, FEE) = $16.20
CONTRACTOR:' J./u.,..iT"~ ~9;47/,.../ 1 lA-vLJ.5 CA-./"'--
ADDRESS: ~,r:J. 'J / ~/f,/ l_J PHONE #: 9.1.r-3:1../")-
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CITY: 1/-<--~7?J- STATE: (},,-f. ZIP: '77 '1'tf-?
CONSTRUCTION CONTRACTORS REGISTRATION, #: J /,"{',., 'Z..-
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E:,PIRES: V-3p'-""
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOi( INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/A?PLICATION IS
CORRECT.
/CL ;flU:
SiOOytiRE
P./'J-:JJ
DATE
FOR OFFICE USE
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RECEIPT #: ():S<\",)..~<..J ISSUED By:!7, ma.cA~ d"o-
TOTAL AMOUNT COLLECTED:Jl J & .6'0