HomeMy WebLinkAboutPermit Plumbing 1994-09-30'ra'
BAcKFLo\,rPREvEslotlr"rli?f; .'dlHAPPLrCATIoN
BUILDINC SAFETY DIVISION
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OFFICE:
INSPECTION LINE:
726-3759
726-3169225 FIFTH STREET
spnrllcFlrlD 0R 97 477
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JOB LOCATION:
ASSESSORS MAP +:
TAX LOT T:
OIINER:
PHONE #:
STATE:ZIPz ?-7>>
BACI(FL0V PERMIT IS $15'00 + $'75 (STATE SLRCHARGE) + $'45 (ADMIN' FEE) = $16'20
CONTRACTOR:
ADDRESS:
PHONE *:
ADDRESS:
CITY:
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CONSTRUCTION CONTRACTORS REGISTRATION *:EXPIRES z 2A,
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECT]ON
Tiio_itog). r aiso srArE rHAr ALL TNFoRMATTON ON THrS PERMTT/APPLTCATToN rS
CORRECT.
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FOR OFFICE USE
DATE OF APPLICATTON:9*€t
RECEIPT #: //9ae
JOB #:
TOTAL AMOUNT COLLECTED:
ISSUED BY:
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