HomeMy WebLinkAboutPermit Plumbing 1996-05-09SPFIT{GFIELE)
BACKFLOV PREVEMION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DTVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JOB LOCATION:
ASSESSORS MAP *:"7
OVNER:
U TAX LOT *:020oo
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ADDRESS:5 PHONE *:7r{ 7- 7271/
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BACKFLOI.I PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:/yl//14!4/-
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ADDRESS:
CITY:
PHONE *:
STATE:ZTPz
CONSTRUCTION CONTRACTORS REGISTRATION *:EXPIRBS:
BY SIGNING THIS PBRMIT/APPLICATION, I AGRBE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PRBVBNTION DBVICE HAS BEBN INSTALLBD AND IS VISIBLE FOR INSPECTION(726_3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
FOR OTFICE USB
TOTAL AMOUNT COLLECTED:
BY:b JOB #,4(,n03 bd44-fu- b-H q,(pDATE OF APPLICATION:
RECEIPT {I: