HomeMy WebLinkAboutPermit Plumbing 1999-04-27rTTI
SPFINGFI.-LD
BACKFLOU PREVENTION DEVICE PERMIT APPLICATION
CITY OT SPRINGFIELD
BUILDING SAFETY DIVISION
%
225 FIFTH STREBT
SPRINGFIELD OR 97477
0l.I]ICE:
INSPECTION ',INE:
726-3759
726-3769
JOB LOCATION:4(+ A) i rules adopted by the Oregon UtilityCenter
ASSESSORS MAP S, 11 O?Iq 0090. you 7
OIINER:numberfor
center. (Note: the telephone
ADDRESS: >49\t 1;tr Centeris 1 I 14b - Kacll
CITY:epc STATE:c), <ZTP t
BACKFLOII PERMIT Is $15.00 + $.75 (STATB SIRCHARGE) + $.45 (ADMIL FEE) = $16.20
coNrRAcron,(l\ /U 50( t^,vl) sLh?r*
f -o- rb ox c1 Kh PHONE *:ADDRESS:
CITY:SrArE: 0 /{Vu ierv*-zrPz 4 7qc
coNSTRUcrroN coNTRAcroRS REGrsrRATroN-*, {i ) O E,: PIRES:nd{ t7r(
By SIGNING THIS PER}'IIT/APPLICATI0N, r AGREB T0 CALL FoR AN INSP: CTIoN oNCE THE
BACKFLOV PRBVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FO] INSPECTION
(726-3769). I ALSo STATE THAT ALL INFoRMATI0N 0N THIS PERMIT/A PLTCATIoN rS
CORRECT.
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FOR OFFICE USB
DATB OF APPLICATION: q I
RECEIPT {I: O 7> TI >
/TOTAL AMOUNT COLLECTED:h)
ISSUED BY:tJ*/
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