HomeMy WebLinkAboutPermit Building 6-6-24
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING.SAFETY-DIVISION
225, FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: 73\\
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OYNER: \)0Sl\e..~ MrHcu'l
ADDRESS: :-5l1 i'1,I/' 8h S-{]n#
CITY: SOn'{lt1 t-;p)u\ STATE:
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TAX LOT #: -' 2., (:j r'D
PHONE #: 7L/~ - 00D5
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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
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FOR OFFICE USE
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DATE OF APPLICATION:(.., -24 - efr A ' JOB ,#:' 01 C?(; 0"6 X
RECEIPT #: nr;;.77) & ~ . ISSUED BY: n _ fY\aQ~ IA d ()
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TOTAL AMOUNT COLLECTED: ~ \ In ')r?\
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