HomeMy WebLinkAboutPermit Plumbing 1994-01-24OFEGO'VCITY OF
g I]{GFTELD
BACKFLOhl PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Spr i ngfi e'ld , Oreg on 97 477
Offi ce:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Map #:Tax Lot #:
0wner:
Address:Phone #z 272€e=
City:4;>4=b-State:Zi p:
T-/
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
_Phone #: -
City:State:Zi p:
Construct'ion Contractors Reg'istration #:Ex pires:
v
By sign'ing this perm'it/appiicat'ion, I agree to call for an-ins_pection once the
bicktiow [revention devite has been installed and'is visible for inspec!lol
(726-3769). I also state that all'information on this app'lication/permit is
correct.
/- z?- ?/2c/rz2
gna Date
FOR OFFICE USE
Date of Appl i cat'ion :*24.q4
Rece'ipt #:Issued By:
Total Amount Collected:/s-?r
Job #: