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HomeMy WebLinkAboutPermit Plumbing 1995-8-28 . BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::~:::~---~-~~~:::--~~==-~:~;:~---~Oq-~~~-;~~OI\~ , ASSESSORS MAP It: IN1:lG.a..N#rlo>"!AJ 1A11'l-'{' ~1\fCr-~'i'AX La'!' 111 \~~\ SDO OtU1 , I OVNER: S'l"CA--N ~ ADDRESS: -:z.,lfo<: ~y V,l'f..-,l..J L... I STATE: PHONE #:l%-gy-y~ ZIP:~llf7L CITY: Sn.I~\~LC:> 017 BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20 CONTRACTOR: ADDRESS: THOMPSON l ^~II]~r,^p~ COMPANY CONSTRUCTION CONTRACTORS REGISTRATION #: (O'bRI PHONE It: ('og{~r:-:SY(o~ ZIP: EXPIRES: (,0 /-~() /ci. ~ / J CITY: ..v. OVA IIOOe! EU(J~Ne, GREGON 97440 STATE: 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 T AT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. , .' ~2~~5" FOR OFFICE USE -------------------------------------------------------------------------------- ~csD~aLP DATE OF APPLICATION: R. ~ \ . C\ e:s RECEIPT It: \~~~\o \.\ 0 ,if!) BY: ~\DCL~OB #: , ' 1;OTAL AMOUNT COLLECTED: --------------------------------------------------------------------------------