HomeMy WebLinkAboutPermit Plumbing 1995-01-14SPRTNGFIE,LD
BACKFLOV PRBVBNTION DBVICB PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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JOB LOCATION:
ASSESSoRS MAP lt , ,/ 7A 3 zs3 3 TAX LOT *:
Ol.INER:f
ADDRESS:PHONB *:
CITY:STATE: 2f ZTP 77rz-
BACI(FLOV PBRMIT IS $15.00 + $.75 (STATB SURCHARGE) + $.45 (ADMIN. FEE) = 516.20
CONTRACTOR:,/r/arz
PHoNE *, 726-{3 z V
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STATB: dr zrPz 7 7/ 77/26a7{/t-r-ltr
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ADDRESS:
CITY:
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CONSTRUCTION CONTRACTORS REGISTRATION S:DXPIRBS:
BY SIGNING THIS PERMIT/APPLICATION, I AGRDB TO CALL FOR AN INSPECTION ONCE TIIE
BACKFLOV PREVENTION DEVICE HAS BBEN INSTALLED AND IS VISIBLB TOR INSPECTION(726-3]69). I ALSO STATB TIIAT ALL INTORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT.
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FOR OFFTCE USB
DATE OF APPLICATION:
RBCEIPT I}:
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TSSUED BY:
JOB {I:
TOTAL AMOUNT COLLECTED:Lo
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DATE