HomeMy WebLinkAboutPermit Plumbing 1999-04-29SPEII{GFI. LO
BACKFLOI.I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STRBET
SPRINGFIELD OR 97477
0l'',rICE:
INSPECTION .,INE:
726-3759
726-3769
JOB LOCATION:173 o fr/a 4.,*^t ts/uJ
ASSESSORS MAP *:
OIINER:
ADDRESS: t) ?) B-,^,s<-a-'
TAX LOT *:
/4-rp PHONE *:
STATEz O ZIP:. '7 '2 2-o /
U r74 S nnrJ i t<_
PHoNE *: ft7-32&>
STATE: a Z-1 ZtPz ? 21za y
-
&
CITY:E er<z ).<-
7
CONTRACTOR:
ADDRESS:?.O, %r
BACI$LOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMII,. FEE) = 516.20
k+-/,'-+
6
CITY:
CONSTRUCTION CONTRACTORS REGISTRATION. #:E]:PIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGRBE TO CALL FOR AN INSP]:CTION ONCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FO]. INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATTON ON THIS PERMIT/A PLICATION IS
CORRECT.
7-2>9 emm
--'-POR OFFICE USB
DATE OF APPLICATION:+-21 -1:
RECETPT #:
TOTAL AMOUNT COLLECTED:
ISSUED BY:
JOB :o5a
CITY OF
aE)
).-o -