HomeMy WebLinkAboutPermit Plumbing 1994-12-08BACKFLOI.'I PREVENTION DEVICE PERMTT APPLICATION
CITY OF SPRINGFIELD ]
BUILDING' SAFETY DIVISION
225 Fifth Street
Springfie'ld, 0regon 97 477
Off i ce:
INSPECTION LiNE:
726-3759
726-3769
Job Location:
Assessors MaP /l:
Litz o 5 o,/'
Tax Lot #:O21o ?2
0wner:
Address i 't-L c)Phone #:
City:f,State:a,4,
Backflow Permit is $15.00 + $0.75 State Surcharge + '49 2#)*"tt,
e y -r lo^
Li p:771 77
Phone #:744 - - / ".F _
7.1 p: 7z,l>8
Contractor:
Address:
City:
o o /tX
*
State z o/,
,,/
Construit'ion Contractors Reg'istration #:a Ex pires:. tlsr/rs
By signing this permit/applicat'ion, I agree t'o call for., an.i;nspection. once the
bickfiow [revention devib'e has boen insla'l]ed and is visibie for inspection
(726-3769). I also state that a'll information on this ap'piication/permit is
correct
S'igna ure a e
FOR OFFICE USE
Date of Application:
Receipt #:/EL q3 Issued By:
Total Amount Co'l I ected :
L
2-o
Job #:
Sr'EIINGFIELO
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