HomeMy WebLinkAboutPermit Plumbing 1994-08-24fre>
225 FIFTH STREET
SPRINGFTELD OR 97477
!SPBIllGFTELD
BACKFLOIN PREVEMTON DEVICE PERM]T APPLTCATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
OFFICE:
TNSPECTION LINE:
726-3759
726-3769
CITY OF OFEGOA'
JOB LOCATION:
ASSESSORS MAP #:
0UNER:
ADDRESS:
CITY:
^6 2'6r-,/'2 TAX LOT #:ad 5/a z>
P ,ry
STATE:
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PHoNE #: -2/f --< Y< />gZIP:
BACKFLOW PERMTT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = 916.20
CONTRACTOR:
ADDRESS:PHONE #:
CITY:STATB:ZIP
CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOI{ PREVENTION DEVICE IIAS BEEN INSTALLED AND IS VISIBLE I'OR INSPECTION
(726-3769). I ALSo STATE THAT ALL TNFoRMATToN 0N TH]S PERMTT/APPLTCATToN rS
CORRECT.
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FOR OFFICE USE
DATE OF APPLICATTON:*-?q.4{
RECEIPT #: / //r'2-ISSUED BY:
TOTAL AMOUNT COLLECTED:6
JOB *:
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