HomeMy WebLinkAboutPermit Fence 2000-10-05CITY OF SPF OREGO'V
SPIr.--GFIELD
DEVELO PMENT SERVI C ES DEPARTM ENT
BACKFLOI{ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFTELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD, OR 97477
(541) 726-3753
FAX (541) 726-3689
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
JOB LOCATION:7C I
ASSESSORS MP +, tI O g >1 \>-TAX LOT *: CO(o SC
OIINER: -lJrr."
ADDRESS:PEoNE *z 775- ?7/7557
CITY: Etyl STATE:zrPzfu€A-!.hoff
BACKFLOV PERMTT rs $15.00 + 1.05 (STATE SURCHARGE) + .45 (ADMrN. FEE) = $16.50
COMRACTOR:,S 1N
ADDRESS: / 7 2C Onr DP PHONE
CITY:STATE: rC R ZIPz e
CONTRACTORS REGISTRATTON *Z //O1/ 7 EXPIRES:o oz
BY SIGNING TEIS PERI.IITIAPPLICATTON, I AGREB TO CALL FOR AN INSPECTION ONCE TEE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTATLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON TEIS PERI.IITIAPPLICATION IS
CORRECT.
1-4/'7-rl ,/ d.r,/. "O
FOR OFFTCE USE
DATE OF APPLICATION:
RECEIPT #:
TOTAL AMOTJNT COLLECTED:
ISSUED BY:
JOB *:
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