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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: 3 s l'l --- s gT- rAx LoT *, a%t: OI.INER: ADDRESS: 3 a I (I s+ree{PHONE #:1 Ll1- 'l&0 CITY:STATE:.Q 0 ZIP z q1 a1 -7 BACKFLOI PERMIT IS $15.00 + $.75 (STATE STIRCHARGE) + $'45 (ADMIN' FEE) coNrRAcront -( e IF ADDRESS: ]0-7 o. sfKee PHONE *: CITY:STATE: O TE 0 zrP: q11-1') " 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. Ll-tQ-1G IJAT}.; FOR OFFICE USE DATE OF APPLICATIzlt RECEIPT $: ./6.2 0 JOB ltr2 r >/ ISSUED BY: $16. TOTAL A},IOUNT COLLECTED: aCITY OF To r- I)" [^ o )