HomeMy WebLinkAboutPermit Plumbing 1996-6-11
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BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION:
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TAX LOT II: 0/0/ 2r
. ASSESSORS MAP II: /7 0.3> 2- & /-;)-
OYNER: I/~" /1 .l)la:l7~'n.f;t {p
ADDRESS: P;;;-1' JlMJ.J"?7 &i~1€. tI PHONE #: Ljt/{, -{,;:).il
CITY: C;I~( J STAfE: r::v~ ZIP: 97077
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: P.J1jKF:~d:'-p_ ~ . Mmes a Ih/.uf~l~
Pw #h-i-/Y';:-/'/' ,~.JW/6HONE II: .
CITY: ?~/d ;;P/E: / /\ STATE: /J~ ZIP: 571"'77 .
CONSTRUCTION CONTRACTORS REGISTRATION II: J?,::) 9;( Y EXPIRES: W 9'?
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ADDRESS:
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.
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SIGNATURE I t 0
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DATE'
FOR OFFICE USE
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DATE OF APPLICATION: 0J -- II -- 9&
RECEIPT 1I: n2-/ %&7 ISSUED By:/7.
TOTAL AMOUNT COLLECTED: $ 1/';. d-o
JOB 1I: 9&07;:/
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