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HomeMy WebLinkAboutPermit Plumbing 2000-2-22 -e e: SPRINGFIELD 668 000 .50 CHANGE: ,~IER:059 (3/ 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. * -------------------------------------------------------------------------------- ~/'..a /R'/p' ),;Tri'z:' r 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- J'7 ../ ADDRESS: //(:1 A'd Y '2/,9"9' - 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. r;.4~ " fr6fiATURr: ~?4~- I' /' k-~? -tf'Zl iiATE . FOR OFFICE USE -------------------------------------------------------------------------------- '-- DATE OF APPLICATION: RECEIPT 1I: TOTAL AMOUNT COLLECTED: . JOB 1I: DO~OO a q,g-..o( ISSUED BY: /).:r), a-IY . . -------------------------------------------------------------~------------------