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HomeMy WebLinkAboutPermit Plumbing 1997-06-23SPRINGFIELE, % 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 U 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. u-zz -r7 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