HomeMy WebLinkAboutPermit Plumbing 1999-2-7
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ATIENT/ON:OregOfl jaw requires you to
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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
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\ll()~~ / TAX LOT #: n\\ (1,')
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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
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~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
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ADDRESS: P,o IJOk 'C:/I't~S
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FEE) D $16.20
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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
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TOTAL AMOUNT COLLECTED: \ \ 0 .~) "
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