HomeMy WebLinkAboutPermit Plumbing 1997-05-123FF!XGFtELI,
BACKPLOg PREVEI|TION DEVICB PENilIT APPLICATIONCITI Or SPRINGTIEU)
BUII,DI}IG SAPBf,Y DIVISION
225 TITTH STREET
SPEINGFIELD OR 97477 OFPICE:
INSPBCSION LINE:
726-3759
726-3769
CITY OF SPR oaEGon
JOB IOCAIION: (3 c ''6 L.0 t- .{-.r-.-
ASSESSORS I{AP f:TAX LOT *:
OUNER:o c
ADDRESS:7 b'&PHONE }:tq|-a bct I .
CTTY:STATE: o rf zrP. q\V 77
BAcKFL0lr PERHTT rs 515.00 + $.75 (srATE suRcHARGE) * $.45 (ADurN. rEE) . $16.20
CONTRACTOR:q_a_€ ^\o.r.Q-c'.
ADDRESS:PHoNE il: GX I 706 3
CITY: 4L STATE: 6YL ?IP: 7l var
C0NSTRUCTI0N C0NTRACTORS RBGISTRATION * t (r,.1 a S EXPIRES z ).c Z- 7.6'
BY SIGNING THIS PERHIT/APPLICATION, I AGREB TO CALL FOR AN INSPECf,ION ONCE THEBACKFL0IT' PREVENTTON DEvIcE HAs BBEN rHsteir.gD-eiro rs vTSIBLE ron INSpEcTToN17-?9-77591' r ALso srArE TI{AT ALL rNFoRHAiiox oll THrs pERHTT/AppLrcArroN rscoRRECr.
LC 5.1, 7
rOR OPPICE USE
DATE OF APPLICATION:
RECEIPT $:
q
ISSUED BY:
TOTAL AHOMN COLLECTED::l.r)
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