HomeMy WebLinkAboutPermit Plumbing 1997-03-11r^/l+\
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
SPRTNGFTELO
BACKFLOW PRBVENTION DBVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAT'BTY DIVISION
%
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION:W t\ot u Lt tr
ASSESSORS MAP II:TAX LOT fl:
OUNER:
ADDRESS:o L I ,--'PHoNE *: 7Lc-Gct
STATE:ZTP z
BACKFLOU PERMIT IS 915.00 + $.75 (STATE SURCHARGE) + 9.45 (ADMIN. FEE) = $16.20
S;,*- ?h^ wbCONTRACTOR:
ADDRESS:
CITY:STATE:
CONSTRUCTION CONTRACTORS REGISTRATION *:oL DoQ()
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE TTIEBACKFLOV PREVENTION DEVICE HAS BBEN INSTALLBD AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TIIIS PERMIT/APPLICATION IS
CORRECT.
FOR OFFICE USB
ao \s)Lf- C PHONE *:G g ? - L(cJ^,(
t-(_
DATE OF APPLICATION:
RECEIPT II:21s23 ISSUED BY:
&oTOTAL AMOUNT COLLECTED:
JOB II:
a/
CITY: SrA*, ,,^-, h<) A
/2D n
u-
Ort-
urnr*/9,f