HomeMy WebLinkAboutPermit Plumbing 1992-07-27ct TY OF SPR OREGO'V
BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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Offi ce:
INSPECTION LINE:
726-3759
7 26-37 69
225 Fifth Street
Springfield, 0regon 97 477
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Job Locat'i on :
As s es sors Map ll :1
0wner:
Address, 24C'1 fJ' l1L
Tax Lot #:or171
Phone #:
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C'i ty :4i,nffi,&&State:
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Contractor:h^TMf
Address: _ Phone #:
C'ity :State:Zi p:
Constructjon Contractors Registratjon /l: Expires:-
By signing this perm'it/app'ljcation, I agr99 to cal I for an inspection once the
backf low prevcnt!on devicb has neen instal led and is v'is'ible for inspect'ion
iiZA-:7ogj. I atio state that all information on this appfication/permit is
correct.
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Date of ApPl icat'ion:
Rece'ipt ll:5u 42
FOR OFFICE USE
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Total Amount Collected:
,2'l ,
Issued By:
Job #:t0ttr
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Backflow Permit is $15.00 + $0.75 State Surcharge
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