HomeMy WebLinkAboutPermit Plumbing 1997-05-31SPFIh.GFTELO
BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
r q
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JOB LOCATION: rc ig ut iha(TraG-c+,
ASSESSORS MAP *:i10311/ZL TAX LOT *:OOffD L
OUNER:
ADDRESS: P.O, B o* SZ et PHONE *:TqLl _ aq I b
CITYz t \19LL*,<STATE: o{L ZIpz Q7t/oS
BACI(FL0U PERMIT IS $1.5.00 + S.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:E-nhr{-^a t^^,fr-q.+ A o ,
ADDRESS: ?. o,B-.\ 4tqas PH0NB *: as3- 106)
CITY:STATE: a R-zIPz"/74O{
CONSTRUCTION CONTRACTORS REGISTRATION #:b1 o5 EXPIRES: , .b 6, ?8
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPBCTION ONCB THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPBCTION(726-3769). I ALSo STATE THAT ALL INFoRMATIoN 0N THIS PBRMIT/APPLrCATIoN IS
CORRECT.
S
POR OFFICE USB
DAIE oF APPLrcArroN: 5 '28'12
RECEIPT lt: e {o /
TOTAL AMOUNT COLLECTED:
TSSUED BY:
JOB II: