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Home My WebLink AboutPermit Plumbing 1995-9-14 . BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET OFFICE: 726-3759 SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 :::-~:d:~:::~~~~~~:---~~~~----~~::~~------------------------ I . ASSESSO(1;?II: /7~ ~ z. 7_ /2- OVNER:' ~1///~j ~ f~/ . ADDRESS: qt/7/J.;::t!:::/?~0A . c -/ CITY: C, "'OJ' STATE: _ .:s TAX LOT #: ~/eo PHONE #: II (j) - '-----.:..- 7 (/ c'/~7.'"< r- . . ZIP:5? 7y-r77 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20 CONTRACTOR: ~ ~ ADDRESS: CITY: )j~/9/"""";-//Z')\ - . ......, .~ONSTRUCTION CONTRACTORS REGISTRATION #: STATE: pllONE #: ZIP: EXPIRES: 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. . " ~~ FOR OFFICE USE 9 ~/y- ?S DATE -------------------------------------------------------------------------------- DATE OF APPLICATION: RECEIPT #: /'702-')' TOTAL AMOUNT COLLECTED: .~/~~r ISSUED BY: / (/7 .2..,0 JOB II: 0.5 /~9 (~ ~~' I . _~_________________________________________~_____M~~_M_~_____~_~~___~M~~.~____~~ -- ~~ . '.\ \ -'-, '-, . ~ ". . \.......' """ ',' '\ . ..-..-..... --- .' -.'.".-::--.. .,: ~._--\ --- \ /' "',\ ~,.....-/ ---I, '-. - ~t /:' / .' /- J/ . ~ " \ '\ .~ \ 'j ; --------- Q) v-~.--~~ 'l \ '- , .. .>-,.." . _. -".. ......' / ... .. . \ ~ \ \'., '. I' I ,.