HomeMy WebLinkAboutPermit Plumbing 1997-07-25CITY OF OREGON
SPRTNGFIELD
BACKFLOU PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGF'IELD
BUILDING SATETY DIVISION
225 FITTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
LOT *:
726-3759
726-3769
JOB LOCATION:
ASSESSORS MAP *:
OVNER: 1 l)
ADDRESS:
CTTY:
PHONE *:
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BACKFLOW PERMIT IS $15.00 +(STATE SURCHARGE) * $.45 (ADMIN. FEE) = 916.20
CONTRACTOR:
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ADDRESS:
CTTY:
PHONE *:
faoEtr).STATE:
CONSTRUCTION CONTRACTORS REGISTRATION #:q?
ZIPt Q'zq-27
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, T AGREE TO CALL FOR AN INSPECTTON ONCE THEBACKPLOU PREVENTT0N DEvrcE HAS BEEN TNSTALLED-ar'ro rs vrsrBLE FoR rNspEcrroN[]if;|ll',' r ALso srArn tsai ar,r, rNFoRMAiiou on rurs pERMrr/AppLrcArroN rs
FOR OFFICE USE
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DATE OF APPLTCATTON:
RECEIPT *:
TOTAL AHOUNT COLLECTED:
ISSUED BY:
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