HomeMy WebLinkAboutPermit Plumbing 1990-11-08CITY OF SPR"VGFIELD, OREGO'V
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPlllL(iFlELE,
Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69225 Fifth Street
Springf ield, 0regon 97 477
Job Location:S
Assessors l'laP /l:l7 ov3 ,1 lLl Tax Lot #:
0wner:
Addres s :7 .{yt Phone #: =7 L{7 3t
Ci ty State: C e-Z1 p:
Backflow Permit'is $15.00 + $0.75 State Surcharge
Address:fe Ito l*z Phone #:5
Contractor:8X)
City:
Construction Contractors Reg'istrat'ion /f:
By sign'ing
backflow
(7 26-37 69
correct.
ure
Sta te t\'L-
4b16
FOR OFFICE USE
Job #:
I ssued BY :
Zip:1t Lluh
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this permit/app'lication, I agree to call for an inspection once the
revcntion device'nii b;;; insialled and is visible for inspection
. I also state that all information on this appf icat'ion/permit is
Ex pires:h -::%'q(
/t t 1o
a e
Date of ApPf i cation:tlIJ
Rcce'ipt ll:7
Total Amount Collected:t,.19
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PT1/t 01
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