HomeMy WebLinkAboutPermit Plumbing 1993-04-12BACKFLOI^/ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SP,lllllcFIELE,
Offi ce:
INSPECTION LINE:
7 26-37 59
7 26-37 69
225 Fifth Street
Springfield, 0regon 97 471
CITY OF OREGO'V
Job Location:
Assessors l"1ap lf: I
.) ():r;.,r,/ I j Tax Lot #z ()il'-tn(,
0wner:
Address, bQ4 \Dooc[ b]ps-l-__Phone #:
.An.', -- f-, n-lrl state I aQ Li p:47:ttt
r\
City:-r J'
Backflow Permit is $15.00 + $0.75 State Surcharge
A.contractorzMYaM
Address:
a,
Phone #:
City:Q u a),vtl-State: CA Li pt c) 1'1c,1'/
Ex p'ires:5) alqz
--T
Construct'ion Contractors Reg'istration #:
By s'ign'ing th'is perm'it/appl ication, I agree to cal I for an 'inspection once the
backflow prevention dev'ice has been installed and is visible for inspection
(726-3769). I also state that all information on th'is application/permit is
correct.
1,4-4JV q
Siq a ure
FOR OFFICE USE
Date of Appl i cat'ion :
Receipt #: 5{) 7! Issued By
Total Amount Collected: $ Ia -7S
ql r)\q 5 Job #:
Qts
4zc+tQ
u,xq-oq)q _
Datb