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HomeMy WebLinkAboutPermit Plumbing 1998-08-31SPBINGFIELD BACKFLOL' PREVBNTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SATETY DIVISION % 225 FIFTH STREBT SPRINGFIELD OR 97477 OFFICE: INSPECTION LINE: 726-3759 726-.3769 JOB LOCATION:330 b ASSESSORS MAP *:o3 OIINER: ADDRESS:Dlb CITY: 5 to \aN i'hose AB by cr g5z -001 t$q ZIPz Zt?fz Genter is BACKFLOIJ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN. FEB) = $r.6.20 CONTRACTOR: ADDRESS:PHONE *: CITY:STATE:ZTP CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES: BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOU PREVENTION DEVICE HAS BBEN INSTALLED AND IS VISIBLE FOR INSPBCTION(726-3769). I ALSO STATE THAT ALL INFOR},IATION ON THIS PERMIT/APPLICATION TS CORRECT. No1to fl\SPT;fi\l$ r9s1b'tHl flr 1g0 IAY t0B \S DATE OF APPLICATION: RECETPT *: JOB *:'tlrt,t c--I ?Nv ISSIJED BY: oTOTAL AI.IOUNT COLLECTED: (,, r