HomeMy WebLinkAboutPermit Plumbing 1999-09-24C'TY OF SPRINGFIELD, OREGO'U
SPRIilcF!ELD
THIS PERMIT SHALL EXPIRE IFTHE WORK
BACKFLOIJ PREVBMION DEVICE PERMIT
CITY OF SPRINGFIELD
ATJTHORIZED
APPLrc0BtJlll[ENcED
0FFICE: 726-3759
INSPECTION LINE: 726-3769
UNDERTHISPERMIIISNOT
ORISABANDONEDFOR
BUILDING SAFETY DIVISION ANY 180DAY PERIOD.
225 FIFTH STREET
SPRINGFIELD OR 97477
JOB LOCATION:6/7 r 7/ ?'-
ASSESSORS }IAP ft:!10 3tAt rAXLor*: n36OO
0IINER: .=J /r
ADDRESS:97 7d0 (lar PHONE T:
CITY:STATE:ZIPz
BACKFLOI pERuIT Is $15.00 + 1.05 (STATE StRCHARGE) + $.45 (ADt'lIN. rEE) =$16.50
COMRACTOR:
PHONE *:7g {-a9 '/
/r aZ/Zl
e ZIP:
7tCONSTRUCTION COMRACTORS REGISTRATION *:9d{EXPIRES: V - A-A
ADDRESS:
CITI:
CORRESI.
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By SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FoR AN INSPEqTIoN oNcE THE
BACKFLOH PREVENTION DEVICE HAS BEEN INSTALLED AI'ID IS VISIBLE FOB INSPECTION
<iie-tteg). r ALso srATE THAT ALL TNFoRHATToN 0N THrs PERHTT/APPLrcATrON rs
7-2 /- 77
UAIE
POR OFFICE USE
TOTAL AMOI'NT COLLECTED:lo
JOB *:DATE OF APPLICATION:4-A.+-a
RECEIPT *:5b? D ISSUED BY:
50
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