HomeMy WebLinkAboutPermit Plumbing 1993-12-14SPFItrlGFIELE,
OFEGO'V
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97 477
Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69
Bsz- s IJob Location:
Assessors l"lap lf:()) (:3) I Tax Lot #:
0wner:( r,,h t, tlh, {<
Address , U? ?-s, vqH-. /'Phone #:
*N- 7 :?('s ,/
City:Dr 4 State:o-7_i p:17+71;
Backflow Permit'is $15.00 + $0.75 State Surcharge
Contractor: €--t P ' ,rr.ttv.,j</
-Phone
# i
--
C'ity :State:zi p:
Construction Contractors Reg'istration #:Ex p'ires :
By sign'ing this permit/applicat'ion, I
backflow prevent'ion device has been i
(726-3769). I also state that all in
correct.
S gn ature
agree to call for an inspection once the
nstalled and is vis'ible for inspect'ion
formation on this application/permit is
t fuk3nffie-
FOR OFFICE USE
Total Amount Collected Q l<>1
os
4gDate of Appf i cation:
Receipt il:
l? / t -rLqz Job #r cl4l?
,I /Sf,Issued By
aC'TY OF