HomeMy WebLinkAboutPermit Plumbing 1991-01-04BACKFLOW PREVENTION DEVICE PEBI4IT APPLICATION
CITY OF' SPRINGFIELD
BUILDING SAFETY DiVISION
SPRI]{GFIELE,
Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69Z?5 Fifth Street
Sprinqfield, 0regon 97 477
OREGO'VCITY OF
Job Location:5
Assessors l'laP ll:
0wner:
Addres s :tl 7u a ,/
City:State:E-
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor :
Address: /
State:
r'2
Phone /l:
zi p:
i on ll:4{3 Ex pires z l'-li -9 Ila
4-7
FOR OFFICE USE
Tax Lot #:o
Phone #:a ,/ b t ,/lo/
Zi p:
C'ity :
By s.ign.ing this perm'it/application, I agr99 to call for an inspection once the
backftow prevent!on OnuiL! nu, b;;; iniiatled and is visible for inspection
(726-3769). r ajio iiate that ail information on this app'lication/perm'it is
correct.
Construction Contractors Registrat
gna ure
a
Total Amount Collected:
Issued BY:
Job #:7 /ce r/
Date of APP'l'icat'ion:
Recei Pt /l:I 4loz
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