HomeMy WebLinkAboutPermit Plumbing 1993-06-21CITY OF SPBINGFIELD, OREGO'V
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRiNGFIELD
BUILDING SAFETY OIVISION
!SPFI,{GFIELD
Off i ce:
INSPECTION LINE:
7 26-37 59
7 26-37 69225 Fifth Street
Springfield,0regon 97 477
Job Locati on :44+h
As s es sors l'1aP /l :nLo Z ./ Tax Lot #h)
0wner:
Address:
C'ity :
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\\se{3. 44+h Phone #211 b -zqbz
(--State E-t€-7-i
Backflow Perm'it is $15.00 +$0.75 State Surcharge
)-iJ-r\evContractor:
Address:\ls? 3' q{t\Phone #: t)LL l.- zrt uz
C 1Lt-lVC'ity i1 d_
th'is permit/app'lication, I agree to
evention dev'ice has been instal led
I also state that all information
Z1 p:
cal I for an insPect'ion once the
and is vis'ible forinsPect'ion
on this app'licat'ion/Permit is
State: O lZ
construct.ion contractors Registrat'ion #; Exp'ires:--
By sign'ing
backflow pr
(726-376e ) .
correct.
gna ure a
FOR OFFICE USE
Date of Appl i cat'ion :-2/-7 1 Job#
Receipt il:Issued By
Total Amount Collected:/5 7{
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