HomeMy WebLinkAboutPermit Backflow Test 1998-8-31
.
.r
. ,
THIS PERMIT SHAll EXPIRE IF THE WORK .
AUTHORIZED UNDER THIS PERMIT IS NOT '
COMMENCED OR IS ABANDO calling the center, (Note: ,the tele ho~e
. NED FOR number for the Oregon Utility Notifl
,~NY 1pr' r~~v PERloI!ACKFLOI/ PREVENTION DEVICE PERMIT APPLICf{!'~~ris 1-800-332-2344).
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION:
rz Cl3 /l1 c;i.,..tJN:'
e""oi
!
./
.' ASSESSORS MAP 11:
Ol/NER: ,.J p , I.a <y ,j... Il. rJJ__u-" ~ ( If
, I~f~ /
ADDRESS: ~t Eu-~;I-
TAX LOT 11:
PHONE 11: 4 S{y ~0070
CITY:
EJ~-4'"
STATE:
~/)
ZIP: 9? <rul
BACKFLOI/ PERMIT IS, $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: A""cI4.... ,L '??"'e:~" "" 6- II
ADDRESS: ~6 Eo~J rllt
PHONE 11: Cf- ~ ir 0 0 70
CITY: t? u .....-<.
STATE: 0 f{
'/"} /69
ZIP:
7?Y'OJ
CONSTRUCTION CONTRACTORS REGISTRATION D:
EXPIRES:
"
BY SIGNING THIS PERMITIAPPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE TilE
BACKFLOI/ PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT. .
. '~-----7C!:g:;
SIGN11TlfRE ' G/
<;;-';;/ - r "S"
l'iATE
FOR OFFICE USE
::::-::-:~~::::::::~~~17~~---------------------------:::-:~~~J~::)---
RECEIPT lI:m/ ?b~ _ ISSUED By;n, fY'I!1.cJ1 a.JO '
TOTAL AMOUNT COLLECTED:1J I ( d, )0
--------------------------------------------------------------------------------