HomeMy WebLinkAboutPermit Plumbing 1993-09-08r*
CITY OF SPRINGFIELD, OREGON
BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPF*<GFIELD
Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69?25 Fifth Street
Springfield, 0regon 97 477
B?€-r-7v /seJob Locati on :
Assessors l"1aP #:/E -a ?2 Tax Lot #:
0wner:
Addres s :
C'ity :
Backf'low Perm'it is $15.00 + $0.75 State Surcharge
Contractor:
Address:
City:State:
Phone #:
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Phone #:la.aAl - - _
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pi res:
State:
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By s'igning th'is permit/applicatjon, I agr99 to call for an ins-pection once the
bickfiow [revent'ion device has been ins[a1]ed and is visible for inspec!lo!
iTiO-:iOgj. I atso state that all 'information on this application/perm'it is
correct.
Construct'ion Contractors Registrat'ion #:v <p/ Ex
S gna ure
FOR OFFiCE USE
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Date of Application:4-g-4= Job #:
Receipt lt: /z>/?O Issued BY:
Total Amount Collected:
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