HomeMy WebLinkAboutPermit Plumbing 1995-09-14ISPIlI'YGFIELE,
CITY OF SPB"VGFIELD, OBEGO'U
BACKFLOII PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION:
ASSE
OIINBR:
ADDRESS:
OFFICE:
INSPECTION LINE:
726-3759
726-3769
.2 TAX LOT *:&r/eo
PHONE *:?-, -Z
PHONE *:
CITY:STATE:ZTPt
BACI(FLOW PBRMIT IS $15.00 + $.75 (STATE STRCHARGE) + $.45 (ADMIN' FEE) = $16'20
CONTRACTOR:
ADDRESS:
CITY: STATE:ZTP.,
.CoNSTRUCTION CONTRACTORS REGISTRATIoN *:_ EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGRBB TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSo STATE THAT ALL TNFORMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
7t
U
FOR OFFICE USE
TOTAL AMOUNT COLLECTED:
JOB {I:?f:DATB OF APPLICATION:
RECEIPT *:ISSUED BY:
LA
7 U(/A- :.F--
\*