HomeMy WebLinkAboutPermit Plumbing 1998-8-10
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NOTICE: Notification Center Those rules are set forth
THIS PERMIT SHALL EXPIRE IF THE WORK In OAR 952-001-0010 through OAR 952-001-
BA.C15E~R1fr f~~~TION DEVICE PERMlltl9U?l'tbWt\i'll,QlV)taln copies of the rules by
AUTHORIZED UNDER THIS ,veITY OF SPRINGFIELD calling the center (Note the telephone
COMMENCED OR IS ABANDONED FOIIUILDING SAFETY DIVISI~mber for the Oregon Utility Notification
lOf) Center IS 1-800-332-2344).
2\tf(I1!ltflf'Ys%.~IS'l.~ OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION: /7/0 (EI//Tt.3;1/t1))/!---L.
/7 ()3:J5' 3 q;
OIlNER: 11-11/1 V 5 j)/ 22 A-
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ADDRESS: /7/0 !:ENTE/I//V//f-L
CITY: 5;ttZnv 6'- t,,-,--7 I?
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ASSESSORS MAP #:
TAX LOT #. OlC;(Jb
STATE.
PHONE #: 7'17 - 4'fLfS'
O~ ZIP. 19c;J7
BACKFLOII PERMIT IS $15.00 + $,75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20
CONTRACTOR: 1'U/IA/
ADDRESS: I ? J .,
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CITY: ?-_I A ~ ~1V t
STATE:
PHONE #.
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0fJr,- J'-t'lL/
ZIP: 99'/6'-/
EXPIRES: tiff
CONSTkUC1iON CO~TRACTORS REGISTRATION #:
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCr THE
BACKFLOII 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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SiGNATURE
fI/(0/r7
DATE (
FOR OFFICE USE
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DATE OF APPLICATION:
RECEIPT #:
'b/fb /q 2
TOTAL AMOUNT COLLECTED:
ISSUED BY:
lc- 2-e)
JOB #: fg 0 9'1 &
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