HomeMy WebLinkAboutPermit Plumbing 1998-06-16SPFIHGFIELO
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BACKFLOII DEVICE PERMIT APPLICATION
225 FIFTH STREET
SPRINGFIELD OR 97477
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JOB LOCATION:
ASSESSORS MAP II 07 OC rAxLor*,5oo
O}JNER:
ADDRESS:6r PHONE *:
CITY:srArE: u /-ZTP,.
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BAC1(FL9g pERMTT rs $15.00 + $.75 (STATE SIRCHARGE) + $.45 (ADMIN. FEE) = $16'20
OFFICE:
ON LINE:
726-3759
726-3769
2../n-:t fizC-CONTRACTOR:
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REGISTRATTOI.I *:
PHONE *, A 7A(ADDRESS:
CITY:
CONSTRUCTION
STATB:C/L-
FOR OFFICE USE
ZTP
EXPIRBS:
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BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE TTIE
BACKFLO\.I PREVBNTION DEVICE UES SNTN INSTALLED AND IS VISIBLE FOR INSPECTION
7iz.o_ztog). r ALSo srATE THAT ALL TNFORMATTON ON THrS PERMTT/APPLTCATToN rs
CORRECT.
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DATB OF APPLICATION:
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RECEIPT {I:ISSUBD
JOB It:
TOTAL AMOUNT COLLECTED:
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BY:1 nnt4
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