HomeMy WebLinkAboutPermit Plumbing 1994-09-12UW SPrlIllGFIELEl
BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
CITY OF SPR OREGO'V
It
IT
JOB LOCATION: A / fL O7fl OT- (;79
IorrrrroRs MAP *:rAX LOr *: 0 7On
OI.INER:)lodaR J Aailo/cl
ADDRESS:
CITY:i r.l
5r PH0NE #: 7yL -?S 7 q
STATE: O*.e? --zrP: ?7/77
BACKFLOV PERI,IIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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:il.**9 O"*J':CONTRACTOR:
ADDRESS:,->5r,PHoNE #: 7/1-?SfY
CTTY:STATE: Ol *'7-n*22_yZZ
CONSTRUCTION CONTRACTORS REGI STRATION #:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCB THE
BACKFLOV PREVBNTION DEVICE ITAS BEEN INSTALLED AND IS VISIBLE POR INSPECTION
(726-3769). I ALSo STATE THAT ALL INFoRMATIoN 0N THrS PERMTT/APPLTCATIoN IS
CORRECT.
X q /-2r'
DATE
FOR OFFICE USE
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JOB #::/ "zaDATE OF APPLICATION:
ISSUED BY:RECETPT +, /y'o7.<
TOTAL AI.IOUNT COLLECTED: