HomeMy WebLinkAboutPermit Plumbing 1997-08-08roR
SPllINGFIELE,
OFFICE:
INSPBCTION LINE:
726-3759
726-3769
PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION:/ / {/ Seq-^o--, +b-*; l-rt-/
ASSESSORS MAP lt:W V &T*;lacs
OIINER:
ADDF.ESSI//c// €a*-t#PHoNE *, 2/Z -3tr
CITY:STATE: t*,.-?ZIP z 72772-v-- JT
BACIGL0LI PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONB *:
CITY:STATE:ZIPz
CONSTRUCTTON CONTRACTORS REGISTRATION *:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGRBB TO CALL FOR AN INSPBCTION ONCE TTIE
BACKFLOV PREVBNTION DEVICE HAS BEEN INSTALLED AND IS VISIBLB FOR INSPECTION
(726-3769). I ALSo STATE TrrAT ALL TNFoRMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
FOR OFFICE USB
TOTAL AMOUNT COLLECTED:
ISSUED BY:
. JOB {}:Qirzc t1TDATE OF APPLICATION:
RECEIPT {}:21