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 //,
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coNsrRucrroN coNTRAcroRS REGrsrRArroN #, 57 / 7 nxprREs ,Ls/qL
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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: