HomeMy WebLinkAboutPermit Plumbing 1997-4-15
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 . INSPECTION LINE: 726-3769
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JOB LOCATION: Lill /1h,if mr1ttu}
. ASSESSO~S MAP'U: /70322L/L.-/ TAX LOT U: 07~!J-r)
OIlNER: I~ I /, .
ADDRESS: 1-(11 11!t4 /itrifh1/ PHONE ll:;20b- 116.' 7/~
CITY: /?( STATE: ()Je. , ZIP/I/f77
BACK~LOII PER a; "S $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN.
CONTRACTOR: UP! rV.iL/ ~ t/nlf --'
ADDRESS:. :< at::; lj)a~;f IA J~v PHONE U:
CITY~4jt1AO OU /STATE: f)~
CONSTRUdtON CONTRACTORS REGISTRATION U: Olt1J077
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FEE) a $16.20
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ZIP: q7tjq()
EXPIRES: JO-3/>l~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT.
,i~URE
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FOR OFFICE USE
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DATE OF APPLICATION:' l(.....tt;-t17
RECEIPT U: :< 5307 ISSUED BY: t~p1
TOTAL AMOUNT COLLECTED: f. (0 ,:f--()
JOB #: Cf7/J 5lf 0
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