HomeMy WebLinkAboutPermit Plumbing 1994-7-27
BACKFLOW PREVENTION DEVICE. PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Job Location: ~('2- ~ / '5 T
Assessors Map #: \ f)()3~_()~~ Tax Lot #:
Owner: AAx7V Lf.! V ;J /1-/ (,.! 1/.lJ /iI F1<~
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Address: 2 7 J 7 j), .? 2 /lJ} ')/-; Phone if:
City: . J ~ /5) State: AI(
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74'7-/d~ J
Zip: /'7 <I?a
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: ItGAJjI3< !--qAQjC;//? /~
Address: Pi tJ v ?? N 4 }- L
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City: ~;(~)L7~ State:
Phone if:
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Zip:
17~Z5 7
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Construction Contractors Registration #:
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Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention ~evice has been inst~lled and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct. '
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Uate
FOR OFFICE USE
Date of APPlication:3h,?/ r1 J~g:. 91://1.7
Receipt g: /~~ Issued By: .~~
Total Amount Collected: ~ /(,,~.