HomeMy WebLinkAboutPermit Plumbing 2000-01-03CITY OF SPF"VGFIELD, OREGO'V
SPFItlGFIELO
BACKFLOIJ PREVENTION DEVICE PBRHIT APPLICATION
CITT OF SPRINGFIELD
BUILDING SAtrETY DIVISION
Al'lT RE[D:2 $ 16.50
IHANEE:
IABHiER:0iI
225 FIPTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPE TION LINE:
726-3759
726-3769
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ADDRESS: 15 fO (\'\cl-\ Ai,.:,,(la),r,4|j}-.,PrroNE +rlrI]:EB I(
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BACKFL0II PERMIT IS 515.00 + H+ (STATE SIIRCHARGE) * $.45 (AD[IN. FEE) = S15.2O-
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CITY:L STATE:ZTP:
.{ONSTRUCTION CONTRACTORS REGISTRATION *: [=CIP,-+1.,{{1\EXPIRES:q
BY SIGNING THIS PERHIT/APPLICATION, I AGREE TO CALL FOR AN INSPESTION ONCE THE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED AI{D IS VISIBLE FOR INSPECTION
(726-3769). I ALSo STATE THAT ALL INT0RHATION 0N THrS PERHIT/APPLTCATIoN IS
CORRECT.
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POR OFFICE USE
DATE OF APPLICATI0N: /^7"b
RECEIPT S:
TOTAT AHOI'NT COLLECTBD:
ISSUED BY:
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