HomeMy WebLinkAboutPermit Plumbing 1998-04-01SPRT]{GFIELD
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BACKTTdF IT APPLICATION
OFFICE:
INSPBCTION LINE:
DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
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1s0 726-37s9
726-3769
CITY OF OREGOA'
JOB L0CATIoN: ?32q 3zc s/aeef
ASSESSORS MAP *:
ollNER: /\a A
07 rAx Lor *, St/ 0 O
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too*r,ssz 232? 32c Jletet PHONE *: 124-qV33
CITY:N /J STATE: O(ZTP o7?)8
BACKFL0I{ PERMIT IS $15.00 + $.75 (STATE SIRCHARGE) + 9.45 (ADMIN. FEE) = g16.20
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CONTRACTOR:
CITY:Dr4. -ZIPz 9l.tr 7
CONSTRUCTION CON'IRACTORS REGISTRATION #:Lca U37 Z EXPTRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVBNTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
04,/UL aL- &/c{.-_-q - / - zB
DATE
FOR OFFTCE USE
ADDRESS:
a
DATE OF APPLICATION:
RECEIPT #:Z ISSUED BY:
2s2;.A sTEn^)rLr? rt Ln pHoNE *:?39 - 72 /{
TOTAL AMOUNT COLLECTED:LO
JOB {I:lSotN?
STATE: