HomeMy WebLinkAboutPermit Plumbing 1990-05-16SPRi}U6FIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97 477
Offi ce:
INSPECTION LINE:
726-3759
726-3769
OREGON
Job Location: 4lrZ i{ Zfih *
Assessors Map #:11 o'Lz it L)
Owner:
Tax Lot #: ()()c)
Address , 4b f 0r.i iq* tf
C'ity : *n n+{\, olA State z 0 Ln)
Backf'low Permit 'is $15.00 + $0.75 State Surcharge
't,.ern]yr..,. o(cof\?L b1Da.u t Pnenf
Phone #
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Phone #: 74 7 v&74
State:cE-Zi p
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Address:
C'ity :
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Construction Contractors Registratjon #:rul*pires: *l/f+Ex
By signing this permit/appf ication, I agree to calI for an 'inspection once the
backflow prevent'ion device has been installed and is vis'ible forinspection
(726-3769) . I al so state that al I 'information on this app'lication/permit 'is
correct.
5-,/t 7t
Signature 7---=Date
FOR OFFICE USE
lotal Nrnount to\\ected:
lssued By:
I 00 lrZ)Date of Appf ication:5-t b -?o
Rece'ipt #:101 b
Job #:
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CITY OF
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