HomeMy WebLinkAboutPermit Plumbing 1990-01-24SPRTYGFIELD
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97 477
0ffi ce:
INSPECTION LINE:
726-3759
726-3769
CITY OF SPR"VGFIELD, OFEGO'V
Job Location:D5
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Assessors MaP #:- D?'7 Tax Lot #:n2 4co
0wner:hsrnru
Address:Phone #:
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Backf'low Permit is $15.00 + $0.75 State Surcharge
Contractor:1 {Wum
Address:Phone #:
State:fiL Zi p:2
Reg'istrat ion *, ?D')73t'b zxPires:()
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By signing this perm'it/appl ication, I agree to cal I for an inspect'ion once the
U'u.f.fio* [revention devit'e nas neen installed and is vis'ible for inspec!lol
iTiO-giOgj. I atso state that all information on this applicat'ion/permit is
correct.
City:
Construct'i on Contractors
gn e a e
FOR OFFICE USE
Total Amount Collected:5.-1 b
Job #:?o 0ttFDate of Appl i cat'ion :I'2'l -q 0
Receipt #t{y {Q Issued By:
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