HomeMy WebLinkAboutPermit Plumbing 1994-09-30SP'IIlrlGFIELE,
BACKFLOIN PREVENTION DEVICB PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVTSION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-37 69
OREGO'UCITY OF SPR
JOB LoCATI0N:
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ASSESSORS MAP #:/,er ?/TAX LOT *:
OVNER:
ADDRESS:
CITY:
PHONE #:-/^-= ?>
an/-2STATE:ZTPz
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16,20
CONTRACTOR:
ADDRESS:PHONE f:
C]TY:STATE:ZIPz
CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769>. r ALSo STATE THAT ALt TNFoRMATToN 0N THrS PERMTT/APPLTCATToN rS
CORRECT.
d3o
FOR OFFICE USE
DATE 0F APPLICATI0N: ?- 7a-7c/
RECETPT +. //% > TSSUED BY:
TOTAL AMOUNT CoLLECTBD,, ,/6. ?a
JOB *:?/
*=*
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