HomeMy WebLinkAboutPermit Plumbing 1996-07-29SPRINGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGTIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JOB LOCATION:
ASSESSORS MAP *:
E S
TAX LOT *:
0IINER: S
ADDRESSt iR{N. '{L !u PHONE #:
CITY:STATE: O zrp: Q'l 18
BACKFLOV PERMIT IS 515.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHoNE +, lrER-(444
CITY:STATE:zrP: q'l .lo.l
CONSTRUCTION CONTRACTORS REGISTRATION *:t-l L q 5 EXPIRES:a- ql
BY SIGNING THIS PERMIT/APPLICATION, I AGRBB TO CALL FOR AN INSPECTION ONCE THE
BACKFLOW PRBVBNTION DEVICB HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE TTIAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
1-x-1 c
DATE
FOR OFFICE USE
DATB OF APPLICATION:
RECEIPT f,:
/
ISSUED BY:
TOTAL AHOUNT COLLECTED:a 0
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CITY OF
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