HomeMy WebLinkAboutPermit Plumbing 2000-2-22
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SPRINGFIELD
668
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.50
CHANGE:
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BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225. FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
.' ASSESSORS MAP 1I:
JOB LOCATION: 'I77/lJd/a II"
11033'73/
OWER: 1/5 /f'onK
ADDRESS: Zt? f'?' I}' C
CITY: tf;~(hdn1
TAX LOT 1I: Ii .;10c.
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STATE: .t?r
PHONE 1I:5""'.7~~t7/- ///J"t'/
ZIP: /;7~ft:7
BACKFLOV PERMIT IS $15.00 +1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR: //;, ., ~/ d /1? o-r' ht7 'k t-
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ADDRESS: //(:1 A'd Y '2/,9"9'
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CITY: Cr'/f7~he a".. STATE: ;!"'y.'J.&-d?/' ZIP:r'7f't?2
CONSTRUCTION CONTRACTORS REGISTRATION 1I: 7'/'.?t?~ , EXPIRES: ~-en?
PHONE 1I:~~.>-t?S-~/
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL' .FOR AN INSPECTION ONCE THE
BACKFLOV 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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. FOR OFFICE USE
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DATE OF APPLICATION:
RECEIPT 1I:
TOTAL AMOUNT COLLECTED:
. JOB 1I: DO~OO a q,g-..o(
ISSUED BY:
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