HomeMy WebLinkAboutPermit Plumbing 1994-08-29SiPRI]iGFTELD
BACKFLOII PRBVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STRBET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-37 69
C'TY OF OREGOA'
JOB LOCATION:
ASSESSORS MAP #:
7zu 2J'-
TAX LOT #:
OVNER:
ADDRESS:PHoNE *: 7UZ*2271
crrY: fPFZ n,STATE:ZIPz 2-'-f
BACI(FLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) * $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONE #:
CITY:STATE:
CONSTRUCT]ON CONTRACTORS REGISTRATION *:EXPIRES .7 - C--'.r =-4--zc)
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACI(FLOV PREVENTION DEV]CE HAS BEBN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769>. I ALSo STATE THAT ALL TNFoRMATT0N 0N THrS PERMTT/APPLICATIoN rS
CORRECT.
I
FOR OFFICE USE
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DATE OF APPLICATION:
RBCEIPT *:ISSUED BY:
TOTAL AMOUNT COLLECTED:?J)
JOB #:
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