HomeMy WebLinkAboutPermit Plumbing 2001-10-15
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CIIT OF SPRINGFIELD
COMMUNITY SERVICES DMSION - BUILDING SAFEIT
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 3b{,7 /1fttI/JGrJ &'2t1rfL (LD
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Assessors Map #: ( "7 Q L I '7 '3 L
Owner: ~ I ~ WE /7' C~L
Address: 3 O.b '/ /-lA-tP<fAj ,fS/l t..IJ
City: sf) f<I tU1 t7k!) , State:' ~
Tax Lot#:
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Phone#:") (,I?- ~ 72J'
Zip: '7?~//
BACKFLOW PERMIT IS $51.75 (includes Permit Fee, State Surchaige&Administrative Fee)
Contractor: 6t( NI'V ~CA1)M
Address:Z.~ 0-.1- A.J$--"
City: ' ~ f Pc/) State: t/?___
Construction Cv.uL.<>ctors Registration#: / o3/.s~
Phone#: ;> 2..(;-~ J s (')
,Zipcr? ,V? J
,Expires: 9' '"'.SO -~o2-
By signing this perrriitlapplication, I agree to call for an inspection onCe the backflow prevention device has '
been installed and is visible for inspection (726-3769)~ I also state that all information on this permit/application
is correct.
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Date
FOR OFFICE USE
Date of Application: / 6/r ,:>'-:-~ (
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, Checked for Delinquencies:
Job #:0 I ~O IIJO ~o
Checked for Historical Status:
VALIDATION:
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