HomeMy WebLinkAboutPermit Plumbing 1997-06-23SPBIIYGFTELE,
BACKFLOV PRBVENTION 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 *:
OIINER: O€6q6l.) B,ssrrues5 PakBfv vtc-.
TAX LOT *: Ae
ADDRESS: es, il*i* BC,lo .PHoNE *: 3a+z-Lzl7
CrTY: €U1dJa STATE: Aaqut.t
BACKFLOI.I PERMIT IS $15.00 + $.75 (STATE SURCHARGB) + $.45 (ADMIN. r'EE) = $16.20
CONTRACTOR:
ADDRESS:LTZ Vhar
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PHONE *:I
CITY:STATE: O4Zqarx>ZTP: 47'lOZ
CONSTRUCTION CONTRACTORS REGISTRATION *:ExPIRES 4/4/qe
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). I ALSO STATE THAT ALL INFORMATTON ON THIS PERMIT/APPLICATION IS
CORRECT.
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DATE
FOR OFFICE USE
DATE OF APPLTCATI0N: 6-27,? 2
RECEIPT *z ?62C6
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ISSUBD BY:
TOTAL AMOUNT COLLECTED:,2a
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