HomeMy WebLinkAboutPermit Plumbing 1997-07-15SPRI!|GFIELD
BACKFLOU PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
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ASSESSORS MAP #:TAX LOT #: O llm)
OIJNER:
ADDRESS:PHONE *:G
CITY:srArg: OiL ZIPz I
BACKFLOW PERMIT IS $15.00 + S.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = 916.20
CONTRACTOR:
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CITY:e STATE: OL l.;pz ?74o ?,)
coNSTRUcTIoN coNTRAcToRs REGISTRATTI *z @)) 7 EXPIRES:/o- 3t'17
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCB THE
BACKFLOU PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATB THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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FOR OFFICE USE
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DATE OF APPLICATI0N: I - / S- fZ
RECETPT *: 6)0o"Yo rssuED BYr /l . ly d-e/4 &t/
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TOTAL AHOUNT COLLECTED:x,
CITY OF
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