Loading...
HomeMy WebLinkAboutPermit Building 6-6-24 , \ BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING.SAFETY-DIVISION 225, FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: 73\\ \'4 ;\\ ' ~+, S~r<\I1-Q~Jd d's OR Q?LF71 ,', .' ASSESSORS MAP D: \ I b2, 3~ OYNER: \)0Sl\e..~ MrHcu'l ADDRESS: :-5l1 i'1,I/' 8h S-{]n# CITY: SOn'{lt1 t-;p)u\ STATE: r J ' TAX LOT #: -' 2., (:j r'D PHONE #: 7L/~ - 00D5 - " B1( ZIP: -9 '7LJl7 BACKFLOY PERMIT IS'$15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20 CONTRACTOR: ' ;;merJo. LandSCCt,j)e ADDRESS: 'ts?-7 4Lo N,~-L'JlI!1'eJJ0 bi7 PHON~ ~:~6-2GJq?( ~ITY: (J ~swe\\' STATE: () R,ZIP: C2{742io CONSTRUCTION CONTRACTORS REGISTRATION #: GZ'l> ( EXPIRES: ~0 BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN.INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS 7;~AU(~ A/ (p!z4/10 ..~NATURE.I-. /' u DATE / I ,. , , , ,. FOR OFFICE USE -------------------------------------------------------------------------------- , . , DATE OF APPLICATION:(.., -24 - efr A ' JOB ,#:' 01 C?(; 0"6 X RECEIPT #: nr;;.77) & ~ . ISSUED BY: n _ fY\aQ~ IA d () - - TOTAL AMOUNT COLLECTED: ~ \ In ')r?\ -------------------------------------------------------------------------------- , ' '~ .J