HomeMy WebLinkAboutPermit Plumbing 1999-04-16225 FIFTH STREET
SPRINGFIELD OR 97477
SPRINGFIT LD
BACKFLOIT, PRBVENTION DBVICE PERMIT APPLICATI0N
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
OI: ]ICE:
A1't'
Notification Center.Those rules are set forth
Utility
P inOAR
You
of the
numberforthe Oregon
726-3759
726-3?69
JOB LOCATION:D
ASSESSORS MAP *:
OIINER:
ADDRESS:
CITY:
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PHONE *:-6L
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BACKFLOI{ PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMII . FEE) = $16.20
CONTRACTOR:
ADDRESS:J I PHoNE *: ?5q.9 ]Sa
CITY: Y /IT AT A ST ZTP:
CONSTRUCTION CONTRACTORS REGISTRATION. #:t)rL E:.PIRBS: 4 ')O *q 1
By SIGNING THrS PERMIT/APPLICATIoN, I AGREB T0 CALL FoR AN TNSPICTIoN oNCE THE
BACKFLOI.I PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FO INSPECTION
(726-3769). I ALSo STATE THAT ALL TNFoRMATIoN 0N THrS PERMIT/A PLTCATIoN rS
CORRECT.
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DTM
DATE OF APPLICATION:L{
RECBIPT II:
FOR OFFICE USE
JOB
TOTAL AMOUNT COLLECTED:
ISSUED BY:lr//\--)-o