HomeMy WebLinkAboutPermit Plumbing 1996-2-21
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BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY-DIVISION
225, FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
JOB LOCATION: ' d.. 1:5" '~ S /,
" ASSESSORS MAP #: / ?-eP~'" -::26... 3 /
O\lNER: ' ~~ L ~A-....-:h P
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TAX LOT #: dP2/p:'
ADDRESS:
PHONE #:
CITY:
STATE:
ZIP:
BACKFLO\l PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
COtlTRACTOR: s: c, I. . PI u Wl bJ 1./11 -I- ).J F ~'"17".;v '1 .
ADDRESS:-B4'".,~()X,.;,6!r6 '" ,l/~-HF4 . P~o.NE~:."r35-~/St:,
CITY: /}FAJrrYA STATE: cO ff / ZIP: 9'7Lj~g
CONSTRUCTION CONTRACTORS REGISTRATION #: 5' 757 B EXPIRES: 7-',2-,...96
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY 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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SIGN UR~
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FOR OFFICE USE
DATE OF APPLICATION: '-z...~ /' ~6 JOB '#:
RECEIPT #: /"20 7'~~, ISSUED BY: ~~ ~
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TOTAL AMOUNT COLLECTED:
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