HomeMy WebLinkAboutPermit Miscellaneous 1998-12-3
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BACKFLOV PREVENTION DEVICE PERMIT APPLICATIO:I
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET WFICE: 726-3759
SPRINGFIE::.D OR 97477 INSPECTIC:l LINE: 726..3769
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r.OMME~CEQQ~ISABANOO~DFOR
OVNER: ....b\o\c,l~~.':-~-f_.~ "!ld'(\W} f'/ ~ l Y\ C . ATTENTION:Oreoon law reouires you to
. . ... \... II follow rules adopted by the OrEl!)qJl.LJti1j!y
ADDRESS: . 't::, 5 SMd. Y\ve.. ~ln.ifin""M r...n'''' fIlQ~nVi!ll'.~p. ~fi71rti '15
r in.QAB2~2:~ffi01 ~ thro~gh OA. R 952-o0~ - Q 7 UO!
CITY:-...l2!:.ff~ 9~l.fti '~'~'~~T"~'lf~~1 I I
ealling the center. (Note: the telephone
BACKFLOV PERMIT IS $15.00 + $. 75 (STATEnl:lrn\lli\11~~".C).rEl90[\;UQlif,\(,I\!_QI~fi~f~ a $16.20
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ADDRESS: )..,Wll.blol]l'\. ~Olv1.e.w !u>;{('"J \,^-
CITY: ;;;!viN\r< i.-1/
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.STATE: (JJl-
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ZIP: 11 'f
CONSTRUCTION CONTRACTORS REGISTRATION i:
SXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN:;?ECTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE "OR INSPECTION
(77.6-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT. ,\PPLICATION IS
CORRECT.
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SIGNATuif.
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FOR OFFICE USE
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DATE OF /;PPLICATION: ) '}. s q l' cJ JO:l 6: 991J1l-
RECEIPT t': (J 3 2- 2.. , '1. t iSSUED BY: l\ 'h/J. <A.----
TOTAL AMOUNT COLLECTED:":;; / (~ J-O
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