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HomeMy WebLinkAboutPermit Plumbing 1993-12-1 . .. SPRINOFIELD BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759, INSPECTION LINE: 726-3769 Job Location: /~?f? ##//?/t:-/PA/ ?r, Assessors 14ap II: 1?-t?3,--:;?'?/-2-:2 Tax Lot '0: ~'::::r2~ Owner: t..AlA/A//F /0 <:: L~.7f'~ ,,; . .. . I' . C? Address: ~~~~ ' ~hone D: City: "')/--?--LZ/ State: p~ Zip: C3?Y?;::> / Backflow Permit is $15.00 + $0.75 State Surcharge Contractor: tP?r-~A ;,/?;;;?/" ~~/?,,~.&.r ~ Address: .P.?? ~x o/Cc;' P- Phone D: "7~.::.. .-=:?2/S- City: l/c=-/Y~/-# State: c:::::>A Zip:_ '9/76-,..;> . . Construction Contractors Registration D: //:3'72.... Expires: ~-';;'~-~y By signing this permit/application, I agree to call for an inspection once the backflow prevention device has been installed and is visible for inspection (726-3769), I also state that all information on this application/permit is correct. ~~/~. S~n'ature 1;<. -J - 5\3 Date FOR OFFICE USE Date of Application: /'2-/-'5'3 Receipt II: //C?~< Issued By: Total Amount Collected: /.c:;'./~ JobD: 930././2_ ~~ /v