HomeMy WebLinkAboutPermit Plumbing 1997-03-06SPtlTNGFIELE)
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DTVISION
225 FIFTH STREET
SPRINGFIELD OR 97477 OFFICE:
INSPBCTION LINE:
726-37s9
726-3769
JOB LOCATION:{t
ASSESSORS MAP II:o
LLE
TAX LOT *:o
0llNER: L l"
ADDRESS:PHONE #:
CITY:r.tNd STATE: D ZIPz ?n nn
BACI$LOI{ PERMIT Is $fS.00 + $.75 (STATE SURCHARGE) + g.45 (ADMrN. FEE) = g16.20
CONTRACTOR:<€
ADDRESS:PHoNE *: 6A 7^ o ? :"2--
CITY:()STATE:ZI?z ?740/
CONSTRUCTION CONTRACTORS REGISTRATION +Z //4/4 NXPIRBS: Z/Z.Yhf
BY SIGNING TIIIS PBRMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TTIEBACKFLOV PREVBNTION DEVICE HAS BBEN INSTALLED AND IS VISIBLB FOR INSPICTION(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIIIS PBRMIT/APPLICATION ISCORRECT.
7- 6- ?7
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FOR OFFICE USB
DATE OF APPLICATION:3-0,- E7 JOB {I:
RBCBIPT *' CJ
TOTAL AHOUNT COLLECTED:
ISSUED BY: /)lha ril C)
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