HomeMy WebLinkAboutPermit Plumbing 1993-12-1
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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'~
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Address: ~~~~ ' ~hone D:
City: "')/--?--LZ/ State: p~ Zip: C3?Y?;::>
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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-,..;>
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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.
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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_
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