HomeMy WebLinkAboutPermit Backflow Test 1999-6-15
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A1TENTION:Oregon laW requires you to
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In H 952-U01-U01 0 through OAR 952-001-
0090. You may obtain copies of the rules by
calling the center. (Note: the telephone THIS PERMIT SHALL EXPIRE IF THE WORK
number for the. Oregon Utility Notification AUTHORIZED UNDER THIS PERMIT IS NOT
CenterlS LP..flJl,::l~_?"I!Ln "
. BAcKFLo'rlPRBVENTION DEVICE PERMIT OO~~EmJRISABANDONEDFOR
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISIO~NY180DAYPERIOD,
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SPRINGFIELD
225 FIFTH STREET OFFICE: 726_3759~
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769 "
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JOB LOCATION: ?r;:; '7 )?t-~K~..., 7,..' ~ c.~ ~ 7-:- .
, ASSESSORS MAP B: ) I ()::<, ;;;L ~ i-f:>, TAX LOT B: Os- I fr1\
OIINER: J-<.L J -:<.A' -<... /? J-J.o.. _.5
ADDRESS: "'P. 0 . ~ '7 L.{ ~ <:.:-
PHONE B:
'144 -d.<olPO
ZIP: Q7 UA I
CITY:
911 C1AU
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STATE:
()~
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: )/u..;;.:;.,<' :Df'.A'~.I9/"'-' t/ -<-#NCJS~""'"
ADDRESS: :l,j-A -;l..G S /?~,4o-v~,..(v La.... '-- PHONE U:
CITY: J L..~ STATE: 0,,('
CONSTRUCTION CONTRACTORS REGISTRATION B: J J 3 '11-
9Jo-3:;u~-
ZIP: 9;:;/,/1J>-.?
EXPIRES: 1./ - ;;l./P"'t::7
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BY SIGNING THIS PERMIT/APPLICATlON, 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. ' '
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SR;?TURE
~'-/.s-:9,9
DATE
FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT B: ()3t.i Irr t;
(.,-IS-Cjq
JOB #: CJS( 1'077
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ISSUED BY:
ck~
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TOTAL AMOUNT COLLECTED: Jl. 11n. ~O
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