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HomeMy WebLinkAboutPermit Plumbing 2000-2-8 (2) . - 508 000 6.50 CHANGE: CASHIER:032 BACKFLOV PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225. FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- , JOB LOCATION: .' ASSESSORS MAP I: OIlNER: JlJ>? ADDRESS: 5'03' h~ 5/. ~~h/ TAX LOT I: //QI'/Vv? 5 CITY: ?'4?~LO / PHONE I: . STATE:. olf! ZIP: cJ7V 77 BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 CONTRACTOR: g<:,R/IIe5'#r'9'# r.er' h' , ' ADDRESS: -Z?'/i7 /?c'v""U7"C-- -&'27 , , 2f:>r-.(./? '" CONSTRUCTION CONTRACTORS REGISTRATION I: t? 8'731l Pl../Jr:. /Xrc. PHONE' I: '7?t'-?8-?t/ ZIP: q 74177 , EXPIRES: 2/1'?/d0 CITY: STATE: oR 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 PERMITiAPPLICATIONIS ' CORRECT...... "a'" / d/' ~.&I' .. ~ ~h /~C> ' bATE' SIGNATURE ./ " '.' . FOR OFFICE USE -------------------------------------------------------------------------------- DATE OF APPLICATION: ~ - '6' - 7... era. . JOB ~: ;;l. ~ 2:> RECEIPT I: c.;oi ISSUED BY: 9<' lJ~ * TOTAL AMOUNT COLLECTED: j 110. ~ --------------------------------------------------------------------------------