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HomeMy WebLinkAboutPermit Plumbing 1999-5-11 -- . . SPRINGFIELD 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:::b!>.......-..n""'" ?",.rn:-'="""....~ ~... t.:_"" I.ln_ I\,. ST". ASSESSORS MAP #: \., (\..... _~ :>.\ TAX LOT #: O~"3"t:\tI OYNER: \~\I\ L....... -:\_ ~'('L '''~ . ADDRESS: 'i'O'~t:: (.;eN>G-"-Tn'.../v ~..._ PHONE #: 93.~-L'l '3'-1 CITY: '-\UI\tt"_T"tOt.L ("'TO" f '.,':'.':., STATE: OR ZIP: -5...7"'-1 't R . BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIK. FEE) = .$16.20 CONTRACTOR: \\.".. k?~ ?c.uW\"'""_ CITY: EUl".E...o STATE: O~ PHONE #: ("~k-\.Lf'i'-l ZIP: 9'.lj(\~ EXPIRES: ~ /11 /01 . . ADDRESS: \ ~:z.s:- \ Chn..r_ "t--..... CONSTRUCTION CONTRACTORS REGISTRATION- #: \'1"'i~ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPSCTION ONCE THE BACKFLO\l PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOP. INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ONAf~E~1~~r'68;r~tf~~?fes~~uto CORRECT. follow rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952-001-0010 through OAR 95:1-001- 0090. YDU may obtain copies of the rules by calling the cent~ ff:JWl; the telephone ;-,u, "berforth~~IIIlY I~Dli"catlOn Center is 1-800-332-2344). ~~. ?-1/ FOR OFFICE USE DATE OF APPLICATION:.c; -11-- 90 RECEIPT #: '339~' ISSUED BY:(\ TOTAL AMOUNT COLLECTED:, <t /1 /J. au ~. JOB it: Otqo JlO fYV) ( J/l fi r1 () --------------------------------------------------------------------------------