Loading...
HomeMy WebLinkAboutPermit Plumbing 1999-9-29 -. . ~., BACKFLOY PREVENTIO~ DEVICE PERMIT APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225, FIFTH STREET SPRINGFIELD OR 97477 OFFICE: 726-3759 INSPECTION LINE: 726-3769 -------------------------------------------------------------------------------- JOB LOCATION: if 6 ') .'5' /-Iz. , ! c-l/i. c.f , ' , _ 1_ _ , , 0 / L (iC{(ttLl''' ,"'.(<(c-tu.......... -, "/'~' - ____3f r .' ASSESSORS MAP II: Ix () 2-6 S / z.. U TAX LOT .11: I ()o 0 mINER: ;1AA/~!1'1 II1C~0b7V ADDRESS: 3&136 c7vT..('J< /.J1U'-y<7 PHONE II~ . 7l(? 2- F J 7 CITY: ('1l.R5t-v-e(! STATE: (J~ ZIP: BACKFLOY PERMIT IS $15.00 + 1.05 (STATE SURCHARGE) + $.45 (ADMIN. FEE) =$16.50 CONTRACTOR: 6MC Me.~ ADDRESS: (,Lf~ UJ.u:f ()7- ~ PHONE II: CITY: ~ STATE: OR. 'g95"- 375;8' ZIP: q1l{~Co CONSTRUCTION CONTRACTORS REGISTRATION II: 1035"10 , EXPIRES: /.:2-15"'-9'/ BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE BACKFLOY 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: , . , __ ~ ~c Z.J-.-' =e:Mrr~~ALlEXPIREIF1HE'~~9_ 91' SIGNATURE 017J:r .:-..'lXRTHISPERIb'AlJ.iE>I~U' ,', . ',.,",.. , COMMENCEDORISABANDONEDFOA ATTENTION:Oregonlawreqwresyo~~o ANYl80DAY'PERIOD. ' , , 'follow rules adopted by the.Dregon Utility , .' , . . ,Notification Center. Those rules are set fort~OR OFFICE USE ~o~~~;~2~~~g~~~~~;~:~~~~i;;;?~-~---~---------------~------~----~-~-I---:;~--- DA'~:.EJI9.fg~~PJ.J!q~'!-:IJ).!~,!e:thet(I.I~L~~rfe 1 f . #c JJ' JOB 'II: 10' 2 ~ kJ numberforthe OreJ.<07l Uti!l!i/ i')!otif.!9at~n /' 1/1, " , RECEIPT rtt:'t~r l~ 1 &(){)_"')'9/'~~)C\ ISSUED BY: f # ("./, TOTAL AMOUNT COLLECTED: . Ie, so ------------------------------------------------------------~~------------------ 0;