HomeMy WebLinkAboutPermit Plumbing 1993-06-01CITY OF OREGO'U
BACKFLOt,l PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
liPllINGFIELO
Offi ce:
INSPECTION LINE:
726-3759
726-37 69225 F1 fth Street
Springfie'ld, 0regon 97 477
Job Location:\\1b ttJW
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As sessors l"laP li:
0wner:
Address:+k
Tax Lot #:
Phone #:lLtb -_v10
Zi p,1W77City:'N&\Q.I-J)State:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:P(onf,o(c-6
Address , ?O L LT(o-z-
C'ity : BU cre,tw State:o'iL-
Construct'ion Contractors Reg'istration *: S-l f(p Ex
Phone #:(. EG'3'(A? -
Zip:711ruo
By s'igning
backflow pr
(726-376e ) .
correct.
Signa re
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this
evenl
ermit/p lication, I agree to call for an 'inspection once the
has been insLalled and is visible forinspect'ion
that all information on this application/permit is
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p'r res :g
a e
b
FOR OFFICE USE
Total Amount Collected:I rs.? t
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Date of Appl i cati on:
Receipt ll:Issued By:
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Job #:
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