HomeMy WebLinkAboutPermit Plans 1990-10-12\+/
/'5^26-.
SPFTNGFIELD
Off i ce:
INSPECTION LINE:
726-3759
726-37 69
BACKFLOI,I PREVENTION DEVICE qEBl4IT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfie'ld, 0regon 97 477
CITY OF SPR'INGFIELD,OFEGO'V
Job Locat'ion :750 NORrH 14.TH
Tax Lot #:-ct3-?c--z
As s cs sors l'laP li :
0wner:DR" MELVIN P. BRYSON JN
Address:8 5 fi T,A
City:E,IIGENF]State:ND
Backflow Permit'is $15.00 + $0.75 State Surcharge
Contractor:
Address:
City:State: .;
Construct'ion C on{ractors Registration /l:
A\r[.rt,p
or)oo
Phone #:26-50747
Li p:e740 5
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By signing this permi.t/application, I
ui.tr1o, i.evcntion dcvice has been i
tTio-:zogl. I also state that all in
correct .
agrec to call for an ins-pection once the
niioiled and 'is visible for inspection
iormat i on on th'i s appl i cati on /permi t i s
d
S gna ure
FOR OFFICE USE
Date of ApPf i cation:
Receipt i/:Issued BY:
\Total Amount Collected:=)'l 5
Jq.b #:
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