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) - - .
--------------------------------------------------------------------------------