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.
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n-fie -Si
FOR OFFICE USE
-
Receipt /l:3z?'a
Total Amount Collected:
Issued By:
Job #:
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Date of Appf i cat'ion :