HomeMy WebLinkAboutPermit Plumbing 1995-05-17SPRI[lGFIELD
BACKFLOIJ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
JOB LOCATION:
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OI{NBR:
ADDRESS:
CITY:
ADDRESS:
CTTY:
CONSTRUCTTON CONTRACTORS RIGISTRATION #:
PHoNE #: 726 €2 /aS
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PHONE #:
BAcl(FL0v PERMIT IS $15.00 + $.75 (STATB SURCHARGE) + $.45 (ADMIN. FBE) = $16.20
CONTRACTOR:
STATE:ZIPz
EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPBCTION ONCE THEBACKFLOI{ PREVENTION DEV]CE HAS BEEN INS?ALLED NNP TS VISIBLE FOR INSPECTION(726-3769) ' r ALSo SrArE THAT ALL rNFoRMAiiow tn rHrS pERMrr/AppLrcATroN rSCORRECT.
U,LL Llt,t-a:J 5t17
FOR OFFICE USE
DATE OF APPLICATION: f.T2-?,
RECEIPT #:TSSUED BY:
TOTAL AMOUNT COLTECTED:-e
JOB #:?Q6<f
C'TY OF