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HomeMy WebLinkAboutPermit Plumbing 1993-04-22CITY OF SPR"UGFIELD, OREGO'U BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISiON SPBIilcFIELO Offi ce: INSPECTION LINE: 726-3759 7?6-37 69 225 Fifth Street Springfield, 0regon 97 477 Job Location: Assessors l,1ap #:)12 Tax Lot #: 0wner: Address:Phone #: 2 />-B/2 State:28,Z1 p,4?>>C'ity : Backflow Permit is $15.00 + $0.75 State Surcharge CContractor: Address:Phone #: 7 //-a 22? City:State:71 pz 4? /2,t Construction Contractors Registration #:?/6 Ex pi res:7^/2-7 By s'ign'ing this permit/appl icat'ion, I agree to cal I for an-'ins-pection once the bickfiow prevention dev'ice has been installed and is vis'ible for inspection (726-3769). I also state that all informat'ion on this applicat'ion/permit is correct. 22. c-.../-zz. ? 3 n-fie -Si FOR OFFICE USE - Receipt /l:3z?'a Total Amount Collected: Issued By: Job #: > Da6Aa Date of Appf i cat'ion :