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 #:
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FOR OFFICE USE
Phone #:
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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 #:
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