HomeMy WebLinkAboutPermit Plumbing 1999-9-30
:..
.
BACKFLOV PREVENTIO~ DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
,
.' ASSESSORS MAP II:
OIINER: ')1 aj tAl I'M
3'f?o t57t--UI'Z/JIZI~
I'! IJ; s IV L. (I
ADDRESS:
lI' b 7,1-::~! &:,1.' c ~ f . r. : ~./:- -= Lot ~
.-~..,.':.'.k:..y.~LHa((Llj r,,{C(C(()C.V,,". ",,'t''-u-
J( 0" (JrAX LOT II: '", ~'- - - "''':c.-:::7-
_ ~__ _ \ . ~ ... .. . _r
A1 C G Wcr---
t2/
PHONE II~ 7'i6-
2$'17
JOB LOCATION:
CITY:
STATE:
o/Z.
ZIP:
BACKFLOV PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50
f .- . u, ~_ u
CONTRACTOR: C:8Mt.~eJ :... _~,
ADDRESS:_ L (p'qg ;-4i.t~rO~-~ PHONE II: ~gq5~~3!{S-8
CITY: L~_: STATE:\_ O~ ZIP: fl1~J.Je/
CONSTRUCTION CONTRACTORS REGISTRATION II: 10357.0. , EXPIRES: 1::l.-/5'-91
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR.I~SPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/ApPLICATION IS
CORRECT.
NOTICE:
11iISPERMITSHALL EXPIRE IFTHE WORK
. ~. '^~~(!.' 'AUTHORIZEDUNDERTHISPERMlTISfiO,!:3 _ q~ . .
. . . _ "11 \ l>-u<-.- COMMENCED OR IS ABANDONED FOR~' 0 -.
/--- S!l.GNAT ~'N:Oregon law requires you to ANY180DAYPERIOD. DATE
fOllow rules adopted by the Oregon Utility . . . .,.,
. Nolificatio,n Center. Those rules are set forth' , . .. .... .
inOAR952.001-001~thro~ghOAR952-001- FOR OFFICE USE . .
0090. You may obtain cOPies of the rules bv
-camnglnecenfii~rNote:rhe~lep.no e -----------------------------------------------
.BA'T~fij'JoI\P'pWCNr1;ONlilityNoti~~lOtllr'J JOB. II: {j<fo~ 'f 9
~nterls 1-8flO."""-,,.rt't!. /l /J . II ; .
RECEIPT II: 0 ~ S-7 3 / ISSUED BY: '.d/ wtM/
TOTAL AMOUNT COLLECTED:
16. )lJ
--------------------------------------------------------------------------------
. .