HomeMy WebLinkAboutPermit Plumbing 1991-09-20____
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
sPFIx-iFIELD
Offi ce :
INSPECTION LINE:
?25 Fifth StreetSpringfield, Oregon 91 417
Job Location:
As ses sors ap tt: I -o2-32-
Owner:
Addres s :
Ci ty:State:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
Addres s :
C'ity:State:
Tax Lot t: ZZ{CtvJeQal€t t "t7-3!-/o7
Phone #:
Zi p:
Phone
7i p:
Ex pires:
all for an inspection once the
d is vis'ible for inspection
n this application/permit is
726-3759
7 26-37 69
Constructi 0n ractors Reg'i s trat i on #:C Z-
By signing
backflow pr
(726-3750 ) .
correct.
gn ature
this permit/app'lication, I agree to c
evention device has boen installed an
also stato that all inf ormat'i 0
r'.,f\
?'Jo 1Q7
D ate
FOR OFFICE USE
CITY OF
Total Amount Collected:
C
I
Job #:Date of App'lf cation:
Recei Pt ll:Issued By