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HomeMy WebLinkAboutPermit Plumbing 1999-2-7 . . ATIENT/ON:OregOfl jaw requires you to fnllnu.I r';' I...,...,....J__._ _". , _ . SPRINGFIELD 1-\ ~oit-U01-001 0 through OAR 952-001: 0090. ,You may obtain copies of the rules by calling the cenler, (Note: the telephone number for the Oregon Utility Notification Center is l-ROO-3i1ACKPIIOII PREVENTION DBVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET OFFICE: 126-3159 SPRINGFIELD OR 91411 INSPECTION LINE: 126-3769 :::-::~:::~---~::---~~:~-;:~---6~~d~---7;~~-;;:;---~~~~-;~~-;---~ \ll()~~ / TAX LOT #: n\\ (1,') to{v-- ASSESSORS HAP #: OIlNER: ~.f"--l{e. ADDRESS: 1'10"3 I.A-frJ-.r 6 i.t. c:{o~ CITY: <:7PI,1rv; k<~c:f ~ ~h ,PHONE I: 7'-11-'7$"'6 STATE: c~ ZIP: 17'-(77 BACKFLOII PERHIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN. CONTRACTOR: f}tPf?E:R.-I-.! 6'''#,t);fC-EMteHf , . ADDRESS: P,o IJOk 'C:/I't~S d'o. FEE) D $16.20 I lq" '::P PHONE .: (P33~706, > ZIP: 9 ,~.,</ .EXPlRES: ~/~ ~ "'''-'' d CITY: ~~ STATE: ~ CONSTRUCTION CONTRACTORS REGISTRATION I: (Plio 5 BY SIGNING THIS PERHIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION (726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS CORRECT. NOTICE: ~SPERMITSHAllEXP'REIFTHEWORk '7 . '7 i AU I HORIZED UNDER n';ls PERMIT I~m- COMMENCED OR IS ABANDONED FOR ANY 180 DAY PERIOD. FOR OFFICE USE ~::-:;~:::~ri~:::-::--~\N)::T[qfDwr TOTAL AMOUNT COLLECTED: \ \ 0 .~) " 5IGNffir tc.-- --------------------------------------------------------------------------------