HomeMy WebLinkAboutPermit Plumbing 1997-06-23SPRINGFIELE,
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SATETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-37s9
726-3769
JOB LOCATION:Z Z8 5P
ASSESSoRS MAP *z /7O7-26<,/rAX LOr *: &azre
OllNER: O
ADDRESS: 353 TT,.W.- TdJD PHONE *: e4Z - bL17
cITy: Euqs>Jcs-SrArB , Ott4 Oxt zwz Q'l.loZ
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BACKFLOU PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16-20
CONTRACTOR:
ADDRESS ZIZ T/**I Buerrt )pHoNE *: W6 )
CITY:6 STATE:6U zrPt ql40z
CONSTRUCTION CONTRACTORS REGISTRATION #:BXPIRES: 4-q'q8
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSo STATE THAT ALL INFoRMATIoN 0N THrS PERMIT/APPLTCATIoN IS
CORRECT.
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DATE
FOR OFFICE USE
DATE OF APPLICATION: I -23 -7 >
RBCEIPT II: 2
io6 +z QTq%2*:ISSUED BY:
.2.TOTAL AMOUNT COLLECTED:/Z -v-
CITY OF