HomeMy WebLinkAboutPermit Plumbing 1995-05-19SPRI}lGFIELD
BACKFLOV PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAPETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
ASSESSORS MAP *:rAX Lor *: & 306
OI{NER:
ADDRESS z 1a me aq alnle PHONE #
CITY:STATB:on zrP q7 q 7 7
BACI(FL0V PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONE #:
(-r"qr' 7'/t-+ ??z
CITY:STATB:ZTPz
CONSTRUCTION CONTRACTORS REGISTRATION *:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOI.I PREVENTION DEVICE HAS BEEN INSTALLBD AND IS VISIBLE FOR INSPECTION
(726-3769). r ALSo STATE THAT ALL TNFoRMATToN 0N THrS pERMrr/ApPLrCATroN rS
CORRECT.
FOR OFFICE USE
DATE OF APPLTCATToN: ,ilr,/tr-/'/
RECEIPT #: / 72. j , ISSUED BY:
-
ToTAL AMoUNT CoLLECTED: / Z ,Lo
JOB *:O- a(r
JoB LocArroN: 3q q 5, 37fu P hrc Cor )n a /;e/i Ofl, Q zq Zz
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EXPIRES: