HomeMy WebLinkAboutPermit Plumbing 2000-2-22 (2)
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SPRINGFIELD
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
668
000
.50
CHANGE:
CASHIER: 059
225, FIFTH STREET OFFICE: 726-3759 '*
SPRINGFIELD OR 97477 ' INSPECTION LINE: 726-3769 .
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JOB LOCATION: YIY m~//? )-r, ,
" ASSESSORS MAP I: 1+0'3531 TAX LOT I: 0=1-'-100
OIlNER: fit!! INt ff tf'm~
ADDRESS: f't7(;? t1:J/:'/ A r'-,.. 1/ ~ I' ' ,R d
PHONE I: '
7' ~~-,r?, (/'?/
ZIP: f'7~t:?/
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CITY: , L::" // ~ 1"/1 ~
STATE:, 0'/
BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.50
CONTRACTOR:_~ 5' /l/L.frP/",tf ..7/;1'!.
ADDRESS: P' ~ /70 y 2/ r9'
CITY: C//~~/~e
CONSTRUCTION CONTRACTORS REGISTRATION I:
PHONE I: ~rS--05'~/
ZIP:?7tyt? Z
,EXPIRES: "/-c1o
STATE: t?/'
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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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DATE
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, FOR OFFICE USE
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RECEIPT I:
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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