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HomeMy WebLinkAboutPermit Plumbing 6-5-28 --) " 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: .J 6~ /~' 1/ dot '1f:V\.-"'('- " ASSESSORS MAP #: Ii (] 'J.,. ) q lj 2.- miNER: /? 't2.-A tJ 1--9 hi () (/ r '< ADDRESS: :l f't;) z/c,f,vt"h'h'<. (Y( CITY: , \' a?r,' ~~,. STATE: t/ 9-3 I QU TAX LOT, # : (j ~ 7 {)o PHONE #: 7 a t & b '19 ~~ ZIP: BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20 CONTRACTOR: (! dI?/ 'f? .rf//If? . ~ ~ - J) ct Y? .-& ~C;I),. ),-(~ dV , " ADDRESS: PHONE #: ? y I.. .'~ :J 9 q CITY: P... a.--:: - v STATE: a\. ZIP: 97f..r rS- EXPIRES : ~ ]7 /-t? ) CONSTRUCTION CONTRACTORS REGISTRATION #: / / ?'/t BY SIGNING THIS PERMIT/APPLICATION, I AGREE' TO CALL FOR AN INSPECTION ONCE THE BACK FLOW PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION .' . 'ii' :;y (726-3769). I ALSO STATE THAT(ALL INFORMATION ON THIS PERMIT/~P~LICATION IS CORRECT. , ,,(,"-... ' iA-/P:r , r, \,Ii 111/""""/ . / )/11/ . . /J 't!:::;// 5Z I. hv ./?'__ . t /7,pr, ~. SIGN TURE ~~ - ))-'0/( S~;;?? - .9 ~ , ' DATE - f/qt 11.-)-J j" FOR OFFICE USE -------------------------------------------------------------------------------- RECEIPT #: ' S'-,Z~~1v 2/ (;7~ ISSUED BY: r !1:1- JOB #: q Gr/7! () DATE OF APPLICATION: TOTAL AMOUNT COLLECTED: [lot tv --------------------------------------------------------------------------------