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HomeMy WebLinkAboutPermit Plumbing 1994-05-03SPFlINGFIELO BACKFLOW PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING, SAFETY DIVISION 225 Fifth Street Springfi eld, 0regon 97 477 0ffi ce: INSPECTION LINE: 726-3759 726-3769 Job Locat'ion :-5 - )€d Assessors Map ll . /'-O-< --iL *32-l^"2Do Tax Lot #: O(zZP 0wner:Z a)4r8. Address ,'?O tB ax 4Sb ,Phone #:7 4 7 -1so1 City:Spz,ntadtgzD State: O {Z Zi p:Qt4t 7. Backflow Permit is $15.00 + $0.75 State Surcharge contracto.'-Q,not - Address r?O ,Bov 1 NZ e^ City:€ =(%-State: Constr#tion Cont,ractors Registration #: gn FOR OFFICE USE Phone #: /-Z-z-/ . -74/- zi p:7z Ex pires: By s'igning this permit/app'lication, I agree to call for an-'inspection once the bickflow firevention device has been installed and is v'is'ib]e for inspec!lol (726-3769). I also state that a'l'l information on this app'lication/permit is correct. 5 /1 /e,/ lJate Date of Appl i cat'ion : Receipt #: -,^ 1- ,/l > Z"Z Issued By: Tot,al Amount Col I ected :.3 /r{o Job #: Uo/ / uta e/=3 1i