HomeMy WebLinkAboutPermit Plumbing 1996-11-12
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SPRINGFIELD .1
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
2.2.5 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 72.6-3759
INSPECTION LINE: 72.6-3769
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.' ASSESSORS MAP It:
JOB LOCATION: :376 ;,} .If) kYna.;.-!ti)/JoJ!. U . Sp.{;--.j 97f../77
/7 () 3/ z;on TAX LOT It: (] / I/J "2.,
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OVNER: . f1 0 k I I ()
ADDRESS: 375;:) ,CI7f-P....-r,YlV.~h,jj/7Ci-l ('{ PHONE #:
SO//I'7c;He/d STATE: O~
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CITY:
7'1/ -/1'0)
ZIP: 'i7y'O/
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.2.0
CONTRACTOR:
ADDRESS:
CITY:
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I
20/S- A)"..c, '1 tf-
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tV~':\.-'-i
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STATE:
PHONE It:
7t-lCo 16J,c2' /
ZIP: 7' J'-/cV
EXPIRES: t"o/3r I p 7
k(..A.tU/1~
'Q~
0000 77
CONSTRUCTION CONTRACTORS REGISTRATION It:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(72.6-3769). I ALSO STATE TIlAT ALL INFORMATION ON TillS PERMIT/APPLICATION IS
CORRECT.
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SIGNATURE U c.....-.J
II' /r z-/ '7(:;
DATE
FOR OFFICE USE
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. DATE OF APPLICATION: / (- (2 -1 ~
:2.37r;;Q
TOTAL AMOUNT COLLECTED:
ISSUED BY:
th.2f) ,"
tlJ1
JOB #: q hft;?, '<
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RECEIPT It: