HomeMy WebLinkAboutPermit Plumbing 1982-3-31
8ACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
8UILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: t2-~DQ '[;1--
Assessors I~ap If: \ ( 001../~\ ~
Owner :"'~.())~ ~10 ~l ('"
Address: 12$D U sJJr--
City: (~"":f d"
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, Tax Lot If:
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, Phone II:
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Zip: (} 7 L(~77
State:
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8ackflow Permit is $15.00 + $0.75 State Surcharge
Contractor: f,w It.lV
Address: Phone II:
City:
State:
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Construction Contractors Registration II:
Expires :.
~ signing this permit/application, I, agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(126-3769). I also state that all information on this application/permit is
correct. '
Sigl1~
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FOR OFFICE USE
Date of Application: ,~-~'I ,..--,'z.,
Receipt fI: ~"'6- '-f(~0 Issued 8y:
Tota 1 Amount Collected:. l 6 .1 ~}
Job #:
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