HomeMy WebLinkAboutPermit Plumbing 1994-09-01SPRIl{GF!ELE)
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
726-3759
726-37 69
aCITY OF OREGO'V
4JOB LOCATION:
ASSESSoRS MAP +t /84<-<':;-/-2 rAx Lor *z #2a/
OIINER:
ADDRESS:
CITY:
PHONE *:
ZIPz
BACKFLoW PERMTT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16-20
CONTRACTOR:
ADDRESS:PHONE #:
CITY:STATB:ZIPt
CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES:
BY SIGNING THIS PBRMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND ]S VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFoRMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
FOR OFFICE USE
7
DATE OF APPLICAT]ON:
RECEIPT #:
----7
-at./-*
JOB #:
ISSUED BY:
ToTAL AMOUNT CoLLECTED, ,/6.2O
Z 7'
OFFICE:
INSPECTION LINE:
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