HomeMy WebLinkAboutPermit Plumbing 1990-12-04BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPRIXGFIELE,
Off i ce:
INSPECTION LINE:
726-3759
726-3769225
spr
F'if th Street'ingfield, 0rcgon 97 477
Job Location:
Asscssors l'1aP ll:Tax Lot #:d4 7a6
0wner:
Address:Phone {l z =-
City:State:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
Address:Phone ll:
City:State:
Construct'ion ntractors Reg"istrati on ll:AD
Signature
FOR OFFICE USE
Date of ApPf ication 1 /?- 7*?O
Recei pt. tt: /8983 Issued BY:
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Ex pires z 5 4i'4'
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By signing this permit/lppljcation, I aqt99 to call for an inspection once the
backflow preventlon OcviLb nut noen installed and is visible for inspection
(726-3769). r aiio siate that aii info*notion on this applicat'ion/permit is
correct.
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CITY OF SPR OREGO'V
Total Amount Collected, /4- C
?s4-oa4-
Job #: ?a/ygs