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HomeMy WebLinkAboutPermit Plumbing 1998-1-26 t. \? BACKFLOY PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION ,> '. ,:'~. ' ,"$ \ 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 .' ~:::::::::::~-:~~~~~~--~~~~~-~~~~----- OYNER: '/(/5YS HeJ/!'7E> L, L, G, / ADDRESS: /0. ~;><" S?.I..-, ~ ~.n.,. PHONE .( 5t5jJ HZ-: 5~2\ . CITY: p.p /0 ~A :;ftisr,,& :~~- ZIP: C'O::/y~~~~; , , BACKFLOY PERMIT IS $15.00 + $. 75 (1tP.T1!?"~~{~ + $'.45 (ADMIN. FEE) = $16.20 , . 1'0'0 V~O U/k 't( ~ . q. ' CONT~CTOR:' K ev-s J-/~).IVII5~A/r~;,,01/.~~1)},~1~ ' /0.& ' '13 -f- ~~.~ (- ) ADDRESS: ~ :;( //~f!) > ~O ~A/4'~~I~~ ~(?3, b C;';;> , STI-::::> ) CITY: PC//' 7 /4- n/! STATE: L' ~ A?' ~ 1! ~~k ZIP: ~ "7.,;2.,?- S- , - U..o v)' ~ CONSTRUCTION CONTRACTORS REGISTRATION It: qq / OS '7 EXPIRES: 9 /~fJ ., , .'. l~ .~. BY SIGNING THIS PERMIT/APPLICATION, I AGREE 1'0 CALL FOR AN INSPECTION ONCE THE BACKFLOY PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION ~~~Eg ~9) . STATE~IIAT. ALL IN~RMATION,ON TillS PERMIT / AP~ ~T~ ft:i! f ShvJ ---,,.. /~6'h~ DA'7' / FOR OFFICE USE -----------------------------------_.~------------------------------------------- ~) JOII 11: Q.~D \(Y: DATE OF APPLICATION: \ · ~f\ ,C\~ RECEIPT It: ~ ~ ~<i\\ () 'J f7\UED BY: TOTAL AMOUNT COLLECT~D:~' ,~ \, w "::' --------------------------------------------------------------------------------