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*
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ADDRESS:
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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<>
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