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HomeMy WebLinkAboutPermit Plumbing 8-1-28 :' ,....~ 'c -" ):- ,t: \? BACKFLO~ PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION if' ,~$ , 225 FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 :::-::::~:::~---~"<:Jl--~~~\---~~~~~(ll~--~~~------------ .' ASSESSORS MAP 1I: \~()~_OY\~~ \j TAX LOT 1I: o~q{)() O~NER: ',.,f',t5Y> Ht:J/!'7E> /iL, L, C~. / ADDRESS: /0. &>" :S-;,./~ ~~~ PHONE .( 50lJ 6f2-: 5'02\ . p.p /of.2b~2t~. " ZIP: -1~r'O~~t$ ~<~;/ /'~~ BACKFLOW PERMIT IS $15.00 + $. 75 (ST~Eit-~CI~t{~ $'.45 (ADMIN. FEE) = $16.20 ~r 0-9 ~-9 ~J$3 . . ' / J M ./ ~ ..o~J$3 {s' -<l ~& ~ <<- n I) rV/ r2 ~ Vn^ ~~h ..o^- )-~ ' <.( 'e>o~~~i~1 ~t'3 ) b (-';;>' ~~ J ,,~ /~ 11 ~.f" ' CITY: Po, 7 /4-n/! STATE: L'K'Ot9 0)- ZIP: ~7.;2.?- S- CONSTRUCTION CONTRACTORS REGISTRATION It: qq /0<;- EXPIRES: 9' he .. / CITY: CONTRkCTOR:' % ev...s /0&".- n ADDRESS: ...-?"l/;JC:;-C{> BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLO~ PREVENTION DEVICE lIAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). STATE THAT ALL INFORMATION ON TIIIS PERMIT/APPL:^C~TbON ff=l> () r ~ CORRECT. //D /, f'JCN'I1 ~xt '4!!// / -- -0 .3>6 ha' FOR OFFICE USE ------------------------~--------71f..-----------------------------?1~----------- DATE OF APPLICATION: I, ,4, f) .V\ ls' I ~ JOB u: 'V'l.YJ\D?1 RECEIPT 11: (\ <6'0 ~t::), ", ISSUED BY: y,\J'{\) TOTAL AMOUNT COLLECTED: ~ \ . ~ "':" --------------------------------------------------------------------------------