HomeMy WebLinkAboutPermit Plumbing 1995-8-28
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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
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, ASSESSORS MAP It: IN1:lG.a..N#rlo>"!AJ 1A11'l-'{' ~1\fCr-~'i'AX La'!' 111 \~~\ SDO OtU1
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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. ~
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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.
,
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~2~~5"
FOR OFFICE USE
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DATE OF APPLICATION: R. ~ \ . C\ e:s
RECEIPT It: \~~~\o
\.\ 0 ,if!) BY:
~\DCL~OB #:
, ' 1;OTAL AMOUNT COLLECTED:
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