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HomeMy WebLinkAboutPermit Plumbing 2000-09-28CITY OF SPR OREGON SPFT..GFIELD DEV ELO P M ENT SERVI C E S DE PA RTM ENT BACKFLOV PREVENTTON DEVICE PERMIT APPLICATION CITY OF SPRINGFTELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIELD, OR 97477 (541) 726-375s FAX (541) 726-3689 225 PIFTH STREET SPRTNGFTELD OR 97477 OFFICE: INSPECTION LINE: 726-3759 726-3769 JOB LOCATION:ol krE Lo* ASSESS0RS MAP *: I -7OZ-t9L/3 rAX Lor *: O \SCO OIiNER:J+- ADDRESS: CITY:5lF t 33ot Pank eR(PEoNE #: 7 /{*2 6 z zrPz77?7 7 rz ,t-?I STATE: C>( BACKFL0I PERMTT IS $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMIN. FEE) = $16.50 COMRACTOR: ADDRESS:PHONE *: CTTY:STATE:ZIPt CONSTRUCTION CONTRACTORS REGISTRATION *:EXPIRES: BY SIGNING TEIS PERMIT/APPIICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TEE BACKFLOT PREVENTION DEVICE EAS BEBN INSTALLED AND IS VISTBLE FOR INSPECTION(726-3769). I ALSO STATE THAT Att INFORI.IATION ON TEIS PERUIT/APPLICATION IS CORRECT. FOR OFFICE USE DATE OF APPLICATTON: O ?Z KO<> RECEIPT #: ' O lL/6t/ISSUED BY: ):c)T0TAL AHOLNT COLLECTED 3 IL '\zJ-)L-\ JOB #: -{(3 rEDr>-1 Z.mLn.. ++Erf ."mc)-trH Ir.J an.n (3(3 r.J L'JC)t l(3 ruff Lrl a1rrtrf(= H {& r.J(3 cl)q] r'l -J-rfD:E);E--1qf]-mmr* 77.. L,JC. trl.. LnF4(} ?-2fr -ooffi