HomeMy WebLinkAboutPermit Plumbing 1991-02-22BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPRINGFIELD
Off i ce:
INSPECTION LINE:
726-3759
726-37 69225 Fifth Street
Springfield, Oregon 91 477
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CITY OF SPR OREGO'V
Job Locat i on :
7C Tax Lot #:As s es sors l'laP /l :
0wner:
Address:
City:
S.#Phone #:
State:lM , Z\PZ
Backftow Permit 'is $15.00 + $0.75 State Surcharge 2- f / 5 '6 4i 'o
Contractor:
Address:P 0ne #:
City:State:Z1 p:q7
Construction Contractors Reg'istrat ion #:
Signa ure
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Ex p'ires ; s/sir/q i
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By s'igning this perm'it/app'l'ication, I aqr99 to call for an inspection once the
backftow prevent!on devitb fras Ueen installed and is visib'le for inspec!l0l
iiiO-:7Ogj. I atso state that all information on this applicat'ion/permit is
correct.
FOR OFFICE USE
Date of Appl i cation:2z
Receipt /l:t ?7r Issued By:7
Total Amount Col I ected :
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Job #:
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