HomeMy WebLinkAboutPermit Plumbing 1998-04-15SPFINGFIELD
qfr,
\r
BACKFLOII PREVENTION DEVICB PERMIT APP TI
CITY OF SPRINGFIELD
BUILDING SAFETY DIVI
ON
1\\\s toB
1\\\s225 FIFTH STREET
SPRINGFIELD OR 97477
726-3759
726-37 69
ASSESSORS MAP *:t70p:3 Ll
hNl
TAX LOT *: Zq A
oIINER: rt\cL44 r /^-l L/e7-LtA,rT'<
ADDRESS; 2*3SO ok tt^o4 r u/*n PHoNE *z 44{- w tl
CrTY: ede6,\t6 STATE, oPG ZTPI 12,@
BACKFLOU PERMIT IS $15.00 + $.75 (STATB SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
C0NTRACTOR: 'TeD t *t Lt u*s f z-r/-t^-Ct/elGr
ADDRESS z (_SZ_= / Av( ^lG KJ)PHoNE *: b88- (.+4+
CITY: €clffirtc€STATE: OeG ZIPz 77 qo./
CONSTRUCTION CONTRACTORS REGISTRATION #, I '71-rg {BXPIRES
BY SIGNING THIS PER},1IT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TIIE
BACKFLOV PREVBNTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE TOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INF0RMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
FOR OFFICE USE
DATE OF APPLICATION:Ll JOB II:
Ll ISSUED BY:RBCEIPT I}:
TOTAL AMOUNT COLLECTED:)-o
JOB LoCArroN: (
"q
I lk o d4*tt t4
+^
Ixoq s