HomeMy WebLinkAboutPermit Plumbing 1999-6-24
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ATT 'N I ;UI". '''ljUO''~'' Utility ,
follow rules adopted by the ~~e~: set forth
Notification Center. Those ru heOAR 952-001-
~0~~~y~~~2~ ~~~?~~~~~s of the rules by , ' '
IIingthecenterN\~1l0Ilt.w.E.V9~ION DEVICE PERMIT APPLICATION
ca b forthe Oregon Utility Notlflcem~ OF SPRINGFIELD
nurn e~enteriS 1_800_332-2344JlUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
SPRINGFIELD
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JOB LOCATION: '-I L/ 3 q1''t:..-<;~ I c-t-v
.' ASSESSORS MAP 1I: /$ 0']. ()$ z. If
OIlNER: D.utlr~VV1 :11-^-
ADDRESl;: L(L/.]L{~ . T't.<:.<; I(,~
CITY: <S/l,r"\/'~
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TAX LOT 1I: tJz,,/o-c
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STATE: flvL
PHONE ti:
-141- ZZ,!'I
ZIP: q 7'17 g ,
BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
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CONTRACTOR: G~ l~s.c...~_ <",QJ'<~..-ts. .
ADDRESS: P< O. tdO"'l' U7-C l/ b 7.' PHONE ji: 461- L/37:;-
CITY: f. ~ STATE: OC ZIP: f'7'-1(Jrf
CONSTRUCTION CONTRACTORS REGISTRATION 1I: G 51- Z- EXPIRES: u----f't
/~ 31- 2P"t/
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLED~Q.IS VISIBLF. FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMiIIlI:Gll~tHIS PERMIT/ApPLICATION IS
CORRECT. THIS PERMIT SHALL EXPIRE IFTHEWORK
AUTHORIZED UNDER THIS PERMIT IS NOT
CQMMENCEDOR IS ABANDONED FOR
ANY 180 DAY PERIOD. . ;, -.2 t.J - 77
DATE
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GNATURE
FOR OFFICE USE
DATE OF APPLICATION: 6!~'(/ tf f
RECEIPT 1I: r5 ~ 'if.:, tit{ ISSUED BY:
TOTAL AMOUNT COLLECTED: If,. u
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JOB 1I:
9?(}66<i
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