HomeMy WebLinkAboutPermit Backflow Test 1999-2-16
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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK. '
S PEn'I.IT Ie: ~IOl
P 'JTHORIZED UNDER THI BACKFLOV PREVENTION DEVICE PERMIT APPLICATIO: i
~OMMENCED OR I.S ABANDONED FOR BUICtDi~GOFSAS:E~I:G;Ix:r~~ON
ANY 1 ~\n 1)/l,Y PERinO
225 FIFTH STREET JFFICE: 72613759
SPRINGFIE::.D OR 97477 INSPECTIO:i LINE: 72.6.,3769
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JOB LOCATION: 2130 Marcola Rd.
ASSESSORS MAP ft: /1,1 3 ~ $"' 8/
TAX LOT r: Oor60
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OIINER: Tr'i -W-Grollo
ADDRESS:llWC:: 1<" ('rVQj- ~ L..L.a..1cp nr
CITY: Corva II i,;. Or
,PHONE ft: ~"L7'i7 77Qf\
STATE: Oreaon ZIP: 97333
, ATTENTION:Oregon law requires YOUUt'II~~Y
,.n ),ElpJ{y the Oregon
BACKFLOII PERMIT IS $15.00 + $.75 (STATE SURCIIAmS?W..r:U$3.!'t,~-~~t!6'se fJllihre6d1ifoZQI
NotificatIOn Cent r. th gh OAR 952-001-
in OAR 952-001-001 ~ rO~es of the rules by
c:ONTRA,CTOl'j: Water F1m< SDec,i.a),~!.'=2 "OQO, YoumaYObtal()~oP U c,'-':,\"h^nO
calling the center. (I UI~~u;;"'f'-otification
n..mh"JIlijfJNRl qpl~_f:j'.'5_~ "j
Center is 1-11Uu-,),)oO -<. ~~ .
.STATE: Oreaon ZIP: 97477
ADDRESS: 912 V street.
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CITY: Snrinafip1d
CONSTRUCTION CONTRACTORS REGISTRATION ft: 126075
SXPIRES: .ll::05-00'
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN::?ECTION ONCE TilE
BACKFLOII PREVENTION DEVICE lIAS BEEN INSTALLED AND IS VISIBLE ;OR INSPECTION
(77.6-3769), I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT, ,\PPLICATION IS
CORRECT.
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FOR OFFICE USE
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TOTAL AMOUNT COLLECTED:
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