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HomeMy WebLinkAboutPermit Plumbing 1992-07-27ct TY OF SPR OREGO'V BACKFLOI,I PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION sPFtts-GFrELo Offi ce: INSPECTION LINE: 726-3759 7 26-37 69 225 Fifth Street Springfield, 0regon 97 477 Ll 2 N l-1b -W Job Locat'i on : As s es sors Map ll :1 0wner: Address, 24C'1 fJ' l1L Tax Lot #:or171 Phone #: o C'i ty :4i,nffi,&&State: a/)I)R'Z1 p ,ol 141 1:IJ 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. I 7- f2L nature Date of ApPl icat'ion: Rece'ipt ll:5u 42 FOR OFFICE USE q3 ,\- Total Amount Collected: ,2'l , Issued By: Job #:t0ttr c Backflow Permit is $15.00 + $0.75 State Surcharge 1 b t5,1 5