HomeMy WebLinkAboutPermit Plumbing 2000-05-11SPIIINGFIELO
BACKFLOU PREVEMION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
il:.{.i{}* iUuJOB LOCATION:
ASSESSORS MAP *:Ct a otificatior,
You ni, ', liltain copies of the fUles bO}JNER:
ADDRES S:PHONB #:
CITY:5 -Fi(STATE:OR ZTP 7- :'-'-^'
BACKFL0W PERMIT IS $15.00 + 1.05 (STATE SIJRCHARGE) + $.45 (ADMIN. FEE) =$16.50
CONTRACTOR:
ADDRESS:
CITY:srATE: AUTHORIZED U!'.JilERTt-itqffi[if]{i r 'i . l
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c0NSTRUcTI0Nc0NTRACT0RsREGISTRATI0N*:ANIY180DAYPERl[qfPIRES:-
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOI PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBIE FOR INSPECTION(726-3769). I ALSo STATE THAT ALL INFoRMATT0N 0N THrS PERMIT/APPLrCATI0N IS
CORRECT.
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DATE
FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT #:
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TOTAL AMOUNT COLLECTED:
TSSUED BY:
JOB #:
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