HomeMy WebLinkAboutPermit Plumbing 1998-05-26225 FIFTH STREET
SPRINGFIELD OR 97477
SPRt'{GFIELD
CATION
OIIFICE:
INSPECTION LINE:
726-3759
726-3769
I
JOB LOCATION:I
ASSESSORS MAP *:lt o ?TAX LOT *:6ci 7 61)
OIINER:
ADDRESS:PHONE *:
CITY:STATE:ZIPz E74A
BACKFLOI{ PERMTT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:
CITY:
PHONE *:
STATE:ZTP
CONSTRUCTION REGISTRATION *:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BBEI'I INSTALLED AND IS VISIBLE FOR INSPECTION
Tize_zlog). r ALso srATE THAT ALL TNFoRMATTON ON THrS PERMTT/APPLTCATToN rs
CORRECT.
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FOR OFFICE USE
DATB OF APPLICATION:5-)d -q'(
RECEIPT *: A
TOTAL AMOUNT CO LLECTED:# / b. N
ISSUED BYz [)fYdch c/ tt
JoB {r,9X0cp tr,
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