HomeMy WebLinkAboutPermit Plumbing 1999-10-21lsPEINGF!ELO
NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
ArrHoprzEo u* JmmEBFryflt$$ryrN
-
DByI gE IEIM r r Ap p Lr cAr r oN
&,nanniruc*9ii33:nNDoNEDFQft:v.oi^"'S1l*r',H'r.,
ANYlSODAYPEI
225-FIFTH STREET OFFICE:
SPRINGFIELD OR 97477 INSPECTION LINE:
726-3759
726-3769
JOB LOCATION:2E,/f ,1/ ZEl
OPEGO'UCITY OF SPR
ASsEssoRS l{AP *, /70}/4qZ rAx Lor *z O7/Oc,
OIINER:r/zr ( loa Tc
Zr{e N ?r pHg1,1B *: 71 7- I V ;tr,c/
ADDRESS:
CITY:lnt .r-O*//STATE: C Z-ZTPzT
BACKFLOII PERI{IT rs $15.00 +1.05 (STATE StRCHARGE) + $.45 (ADMIN. FEE) =$tO.SO
E" rq /r, /o,CONTRACTOR:
ADDRESS:
CITY:/,*//STATE: C L
PHoNE *: ( tr -/ 7//
ZIP:
CONSTRUCf,ION CONTRACTORS REGISTRATION *:7//[z EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE THE
BACKFLOIJ PREVENTION DEVICE HAS BEEN INSTALTED AI'ID IS VISIBLE FOR INSPECTION
(726-3769).I ALSO STATE TEAT ALL INPORI,IATION ON THIS PERMIT/APPLICATION IS
CORRECT ATTEN!'[
fo ,y
Or',2
f,32-?w\
vq0
number
FOR OFFICE USE
10f,, lqfDATE OF APPLICATION:
RECEIPT *:03 51 Sro ISSUED BY:
TOTAL AI{O['NT COLLECTBD:ft.51;
ilh)*: ??tq s 7
rol I
for
./1q7
Center