HomeMy WebLinkAboutPermit Plumbing 1999-08-05C'TY OF OBEGO'U
SPRII{GF!ELO
BACKFLOTT PREVEMION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
JOB LOCATION:
ASSESSoRS MAP *z l70??L 4/ada ()()
OI.INER:
n,awre quires you to
Utility
in OAB 952-001
nter Those rules are Set forth
ln
number the
+$.45 (ADMIN. FEE) =$16.50
PHONE *:
952-001_
the rules byADDRESS:
CITY:
ANYl
BACKFLOII PERMIT S 1
THIS
PERIOD.5.00 + 1.05 (STATE suRcHARcE)
{CONTRACTOR:
ADDRESS:
CTTY:-€STNIEz ffi,Z]Pz Tzqot
CONSTRUCTION
BY SIGNING THIS PERMIT/APPLICATION, I AGRBE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN TNSTALLED AND IS VISIBLE TOR INSPECTION(726.3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
R- q f1
DA:TE
FOR OFFICE USE
REGrsrRArroN # , L.# 1-5o2r/8'.7 nxprRES:1
DATE OF APPLICATION:
'RECETPT *:Blfr5V TSSUED BY:
TOTAL AMOI'NT COLLECTED:
q
o t *: ?Q tog 2
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