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HomeMy WebLinkAboutPermit Plumbing 1995-11-01SPRINGF!ELO BACKFLOW PREVENTION DBVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SATETY DIVISION 225 FIFTH STREET SPRINGFIELD OR 97477 OITFICE: INSPECTION LINE: 726-3759 726-3769 C'TY OF SPF OREGON JOB LOCATION: 3? oN S ? a4.fr t/ ASSESSORS MAP *:/7D3 / I D TAX LOT *:O/6D / O1JNER:rL /t J ADDRESS: CITY:STATE:ZIP BACKFLOU PERMIT IS $15.00 + S.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 C0NTRACa0R: C ADDRESS: Pn> &-x l;-e* I PHONB *1t q //, CITY:STATE:OL ZTPz ?z'/zz coNsrRucrroN coNTRAcroRS REGrsrRArroN #, 57 / 7 nxprREs ,Ls/qL --- BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE THE BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. FOR OFFTCE USE 3? oo 5 Fa kT1 ),,,.,v/PHONE #:-232 DATE OF APPLICATION: RBCEIPT *:TSSUED BY: 2.oTOTAL AMOUNT COLLECTED: JOB {I: