HomeMy WebLinkAboutPermit Plumbing 1997-04-11CITY OF OREGO'U
SPRIItlGFIELO
BACKFLOII PREVENTION DEVICE PERI,IIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
_,_M,ffi
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
JOB LOCATION:J
ASSESSORS MAP *:TAX LOT *:I
OIJNER:
ADDRESS:
CITY:STATE:n/Zf?z
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CONTRACTOR:
PHONB *:/?5 -32t5
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ADDRESS:
CITY:V, nu/o n{?rytP7STATE:ZTPz
CONSTRUCTION CONTRACTORS REGISTRATION #://K72 EXPIRES: q-
BY SIGNING THIS PERMIT/APPLICATION, I AGRBB TO CALL FOR AN INSPBCTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BBEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE THAT ALL TNF0RMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
DATT;
FOR OFFICE USE
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TOTAL AMOUNT COLLECTED:
il
I BY:
JOB II:DATE OF APPLICATION:n
RECEIPT $: d w
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BACIGLOI.I PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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