HomeMy WebLinkAboutPermit Plumbing 1999-5-19
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SPRINGFIELD
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
. CITY OF SPRINGFIELD
NOTICE: BUILDING SAFETY DIVISION
, K:ERMITSHALL EXPIRE IFTHEWURK
225 FIFTH STR ZED UNDER THIS PERMIT IS NOT OFFICE: 726-3759
SPRINGFIELD of\ .'t"'c:n NED FOR INSPECTION LINE: 726-3769
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" JOB LOCATION: ANY 11lJ?.etYi/ER~~ D.r1L>)
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." ASSESSORS MAP #: /703 '1-),.1. ()
OWNER: -;-\-0, ~h I ''''''1 (0'1 ^-t. IMe
ADDRESS: c,").5' I.J (opu-kIJI.J(..p f'.,J
C;r.{'1J
TAX LOT #:
() 2(0/
PHONE #:
7'f7-t:;o <(7
ZIP: 9l'f17
CITY:
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STATE: t?v
BACKFLOW PERMIT IS $15,00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN, FEE) = $16.20
CONTRACTOR: l~ P)U\h bJ/.J. ()'/Ovk-
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ADDRESS: On 1)o.{ J..1l./a'J
CONSTRUCTION CONTRACTORS REGISTRATION. #:
")j) 72. 2-
PHONE #: 45<t-'?MtJ
ZIP: q.>~2...
E:(PIRES: '$>1,2 /Q'I
CITY: ktl.o"...
STATE: (J~
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BY SIGNING THIS PERMIT/APPLICATION, I AGREE ib~~[I(F~RJ~O~'S~\[C~I~NSO~~E~vTHE
BACKFLOW PREVENTION DEVICE HAS BEEN INSTALLJ;;&al,~ V~~![W, lFm~ f.iMtT'~~N
(726-3769). I ALSO STATE THAT ALL INFORMAT)i3 IlfflJl<iA1P~nW.R I mfliJfl'f'\;;'rl'~N~Oft!1
CORRECT, . In Atl9S;Qio1-0ll1 )through 1JAH 9'5~;)Or-
" 0090. You may obtain copies of the rules by
calling the center_ (Note: the telephone
number for the Oregon Utility Notification .
Ceriteris 1-800-332p2 44)jI
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DATE ., '
FOR OFFICE USE
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DATE OF APPLICATION: . S( ('1/71 J'I ~ JOB l!: 1'7'0(, 17 f
RECEIPT #: ()) '-I IJ 7 t[ . ISSUED BY: if {J.
TOTAL AMOUNT COLLECTED: /0- ~
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