HomeMy WebLinkAboutPermit Plumbing 1996-05-20uk^(b
siPRINGFIELD
OFFICE:
INSPECTION LINE:
726-3759
726-3769
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
CITY OF OBEGO'U
JOB LOCATION:
ASSESSORS MAP *:l?032 1/Ll
?'7
TAX LOT #:2)lL
OVNER:t5
ADDRESS: e/qf t)i*-:,*-,t Ao, 1,/U. 02 PHONE #:
CITY:STATE: 2.e zrPz 77/?a
BACKFLOU PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS z 7.A- ./4,2 qD PHONE *:g'/1,70/
CITYz L1^ /*.r,"//.STATE:zI.Pt /7/87
CoNSTRUCTION CONTRACToRS REGISTRATION *z (28 tl EXPIRES: 5
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVBNTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE T'OR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
{-rD 7/
DATE
FOR OFFICE USE
DATE OF APPLICATION:
RBCEIPT #:
0.L
TOTAL AMOUNT COLLECTED:
ISSUED BY:
JOB II:b