HomeMy WebLinkAboutPermit Plumbing 1994-08-24CITY OF OREGO'U
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BACKFLOU PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-37 69
JOB LOCATION:S3\04 Jnoob
ASSESSORS MAP *:
OWNER:
TAX LOT f:
PIIONE +,-1 tcADDRESS:
CITY:STATE:ZIPz
BACI(FLOI^I PERMIT IS 00 + $.75 (STATE SURCHARGE) * $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONE #:
CITY:STATE:ZIP z
CONSTRUCTION CONTRACTORS REGISTRATION +:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOU PREVBNTION DEVICE IIAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE THAT ALL INFORMATIoN 0N TIIIS PERMIT/APPLICATIoN IS
CORRECT.
1
Tn
DA'IE
FOR OFFICE USE
TOTAL AMOI.'NT COLLECTED:\n ${)
B #:4\gts44DATE OF APPLI TION:
RECEIPT #:ISSUED BY:
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