HomeMy WebLinkAboutPermit Plumbing 1995-02-28!SPF!NGFIELD
BACKFLOI{ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION k q
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
OREGO'VCITY OF SPR
ASSESSORS MAP #:Z
OIINER:OloreYrLe l.,uJ*rq
TAX LOT *:
PHoNE #: 7r/ 6 - 26 tSADDRESSzAbIO A/ j*J
CITY:STATE, C R zIPz qly71
BACKFLOw PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS: 7'l ?* I P1 ^ fh e R)PH0NE#: 117*77yL(
CITY:lZucpne
-__J-CONSTRUCTION CONTRACTORS REGISTRATION #:
STATE:oll zrPz cl7 / O,
(,^?l EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE THAT ALL TNFoRMATToN 0N THIS PER!'{ITIAPPLTCATToN IS
CORRBCT.
FOR OFFICE USE
DATE OF APPLICATION:2
REcErPr +z ,/ (t 4 5 L ISSUED BY:
TOTAL AMOUNT COLLECTED:/b Fo
JoBLoCATI0N: 16qO A/ i"-)/r//n)
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