HomeMy WebLinkAboutPermit Plumbing 1999-6-28
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SPRINGFIELD
ATTENTION:Oregoflldw .9qulref )lo~ t ;
follow rules adopted by the Oregon Utility
Notification Center. Those rules are :;et forth
in OAR 952-001-0010 lhrouah OAR 952-001- ,
0090 Y U may obtal'tBACKELOM t:l:'!J.~Y:~.O~ DEVICE PERMIT APPLICATION
. 0 , UVIM~ v ~Y OF SPRINGFIELD
calling the center. (Nate:t~e tele\\ur, NG SAFETY DIVISION
number for the Oregon Utility Notlilvd I
225 FIFT!PrSTREET-flOO-332-?344), Ol'FICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
JOB LOCATION:
.' ASSESSORS MAP U:
OIINER: . Sc.t<'> l)'
ADDRESS: \ \ J (..
CITY: 5r~\J
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/7632-2..Q'L
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TAX LOT U: 62'10/
STATE: <DP
PHONE U: 3<ll,I-.)., l7Cj
ZIP: q]<f77
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: \~ ?\\',^"\)\\"'l'\.~r\\,,l--<\
ADDRESS: \/0'--\ U).."d' ~~ rb Be", J.lqo'7 PHONE U: ?(f<-{-q~91
CITY: tl "1'P'o.R- STATE: ~O ZIP: q7~o1.-
CONSTRUCTION CONTRACTORS REGISTRATIONN~ lldf7:h EXPIRES: ~/ 10/'1<1
BY SIGNING THIS PERMIT/APPLICATION, ITtJl~~~IF~~~~~~~~~~ ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN ~~~~RV~~BBr'f.~Rv1RSPECTION
(726-3769). I ALSO STATE THAT ALL I~m!lJ.\!:lliQlAS\.ANflOOfi~,rmICATION IS
CORRECT, ANY 180 DAY PERIOD. .
SIC
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FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT U: 6 S If b '3 3
TOTAL AMOUNT COLLECTED:
{, /z.i/ '7 f
ISSUED BY:
1 /J Jon U: 7'l()o 7'-1
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