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HomeMy WebLinkAboutPermit Plumbing 1996-9-10 ,. . 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 JOB LOCATION: 9:'2,/ PIN (Je:A/ R f}:1 e;,o Ii- - I . TAX LOT j!: n\\ n I . ASSESSORS MAP j!: \(\() ~a~ l'd-- OIINER: ,..f II -{ fOS5 ADDRESS: ~(p 4 V st. PHONE j!: 7ttl-7i/1 CITY: c.~&. STATE: O('.p ZIP: - , BACKFLOY PERMIT IS $15.00 + $,75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR:W\t\J <...0-1<.. U\.N \) S CftfF- ADDRESS: 17 (c) (AK. v:.. J) /" CITY: ~C:;-, PHONE j!: STATE: Ov' tJ ZIP: 97'/0,/ EXPIRES: J; -"\ 1- q 7 CONSTRUCTION CONTRACTORS REGISTRATION j!: 5 I <. 0 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. a'~ 9'-10 - 'lh bATE . FOR-OFFICE USE ----------------------------Jr1--~-------------------------------------------- DATE OF APPLI~ATION: q. h) '~0 kl --. JOB j!: a tdYJ'?1- RECEIPT j!: r~1.s~r') ISSUED 'BY: \. j'/.Jf!J. ) TOTAL AMOUNT COL~CT~D: 110 .af) - - . --------------------------------------------------------------------------------