HomeMy WebLinkAboutPermit Backflow Test 1999-1-25
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" ASSESSORS HAP ft:
OIINER: ''t(;../ Iff
ADDRESS: / n 5 E
CITY: . &I/d/~'r
BACKFLOIl PREVBNTfmfIO>>l1irellgil'~!\K~re<NlllkI}(ftttlP: I .
f~rfiS~~~\\Qe Oregon Utility ~
BWlliD'11f13;nW~r. -m;y~M1Ys are set forth
In OAR 952-001-0010 through OAR 952-001-
225 FIFTH.. STREET 0090. You may obtain copies of ,.!F~ICE: 726-'
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: .. .. m er or l e, vrejl?n UlIhty NOllfication
JOB LOCATION: ZI Z 2- I11q/,?,#~ljfl~'2344).
/10) ;2:;2 <. ,TAX LOT j!: / '!) ()
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STATE: tf'/'
PHONE ft: )'r/- 757- 27f'e'
ZIP:?/7YJ
BACKFLOIl PERMIT IS $15.00 + $.75 (STATE SURCIIARGE) + $.45 (ADl" eN. FEE) = $16.20
NOnCE:
CONTRA,CTO!'i: ~dl-t'/' /-/.:?"v- ~~l:YP~/TP~ll EXPIRE IF THE WORK .
.' .' o"? /.V AU I H()RIZED UNDER THIS P~-!M:;T JiUII7.r
ADDRESS: 7/(_ <'{-- M....~,,^~_ M l'~ONE ft: .<yfr'lY'fi??'
. ~ ~ _......-..~-~ V" ,::i A!:lANu Ncu r-UN .
CITY: )AN/7Q,h-i!/L PSTATE:n,o#,I;:'R/nn ZIP:1'7Y77
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CONSTRUCTION CONTRACTORS REGISTRATION D: /2,{ t:J 7.5 EXPlRES:~~~
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN::?ECTION ONCE TilE
BACKFLOIl PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE 'JR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT. :\PPLICATION IS
CORRECT.
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/~75 -f' f'
I5A'.1::
FOR OFFICE USE
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DATE OF J;PPLICATION: 1/ Lr / 97
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RECEIPT I': ~ J z.~!-2.. ISSUED BY:
TOTAL AMOUNT COLLECTED: /6. 2c.J
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