HomeMy WebLinkAboutPermit Plumbing 1996-7-24
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SPRINGFIELD
BACKFLOV 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: fl55 (.0. HM.l0u)
. ASSESSORS MAP It: /7(,)~] 72 J
OIlNER: So Dp.,\~<i r- \'E:.~ ~u...t>D\....
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ADDRESS: I ~ q (") N . '4 'l IJ~
CITY: s,? Po. \ A)~ ~;~\~
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TAX LOT It:
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STATE:
PHONE 1I.:
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ZIP: 3..2.:fjj
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN.
CONTRACTOR: ~ L.u\ N ~\ V ~." 'So p' \) M(l..., '\ "'" 1
ADDRESS: .-: 5 :l. 5 :\" ~ \J iN j R Q PI~ PHONE It:
CITY: t:..U'1~r..)e: STATE: (\~Q{)"':)
CONSTRUCTION CONTRACTORS REGISTRATION It: 1'1(" C\ 5
FEE) = $16.20
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c,~- 1<./'1L/-
ZIP:~
EXPIRES: (~- 't:1___
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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pATE
FOR OFFICE USE
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DATE OF APPLICATION: 7-:Jlf 4 ~
RECEIPT u: 12 (,J (T'/:?( ISSUED BY:
TOTAL AMOUNT COLLECTED: \ {fo' . )'/J
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JOB U:
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