HomeMy WebLinkAboutPermit Signage 1995-3-10
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SPRINGFIELD
BACKFLOY PREVENTIO~ 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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. ASSESSORS MAP #: ---UCffi.11B TAX LOT #: ("[):V.1J
O~ER:~\n~~rlo~ (\~.
ADDRESS:~ .0. _ ~~'\-\\
CITY: UJ~
BACKFLOY PERMIT IS $15.00 + $.75
PHONE #: ~?4.~
STATE: \. ~O~Of\
(STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
ZIP:
CONTRACTOR:_ hflQ 0 n&'~
ADDRESS: \C\~a ~ Vi UoM &: ' PHONE #:
CITY: PfY'1J11.Q STATE: , lli.J
CONSTRUCTION CO~RACTORS REGISTRATION #: \\ ~~
?A~. \4~
ZIP:~14O)
EXPIRES: f).\.~ ,. qs
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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DATE OF APPLICATION: ~~. \D.qS ,1" .
RECEIPT #: 11.o~'1? ~ ISSUED BY: ~)I~CUr\.)
TOTAL AMOUNT COLLECTED: \ \ 0 . W
JOB #: q4-I2-S ~
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