HomeMy WebLinkAboutPermit Plumbing 1996-04-16SPFI'{GFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY. DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JOB LOCATION:
ASSESSORS MAP T:
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OI.INER:
ADDRESS: 3 a I (I s+ree{PHONE #:1 Ll1-
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CITY:STATE:.Q 0 ZIP z q1 a1 -7
BACKFLOI PERMIT IS $15.00 + $.75 (STATE STIRCHARGE) + $'45 (ADMIN' FEE)
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ADDRESS: ]0-7 o. sfKee PHONE *:
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CONSTRUCTION CONTRACTORS RBGISTRATION #:J q :.rA EXPIRDS:1 -qc
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE THE
BECTFI,OV PREVENTION DEVICE HAS BBEN INSTALLED AND IS VISIBLE TOR INSPECTION
<7zo-gzogl. r ALSo srATE TtrAT ALL TNFORMATTON ON THrS PERMTT/APPLTCATToN rs
CORRECT.
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FOR OFFICE USE
DATE OF APPLICATIzlt
RECEIPT $:
./6.2 0
JOB ltr2 r >/
ISSUED BY:
$16.
TOTAL A},IOUNT COLLECTED:
aCITY OF
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