HomeMy WebLinkAboutPermit Backflow Test 1998-9-15
.'
.
Ih
. ~J> V~C
...,u~ ,o.l' ~
SPRINOF'El;Q 'I .
'-l1. 'J..o'"
."/! ,
BACKFLOY PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFIcE: 726-3759
INSPECTION LINE: 726-3769
--------------------------------------------------------------------------------
JOB LOCATION:
f}"""-e 34B"JF .~~DJltft/'
,/ 955 OCLk ~J_~ PI,,--=<-
ASSESSORS MAP 1I: 0--00 u u v <70 a
d.n:JPLT #...-.....f'"7 'J.,,,
r t' ~ /"r/t? /
TAX LOT 1I: 6(::; c: =
OYNER:
ADDRESS:
PHONE I:
CITY:
STATE:
ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR:
1:?:J:>I1j~ ~ .?C-A'P/'~
. . -----
///'1TtI ~^", .', ,/
v
CITY: k~
PHONE I:
7J!/-~1)t?.D
ZIP: 47//j}:3
ADDRESS:
STATE:
~
CONSTRUCTION CONTRACTORS REGISTRATION 1I:
/77_70
I
EXPIRES: q /I
,
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. ' Al '1 i::NTION:Oregon law requires you to
, follow rules adopted by the Oregon Utility
Notification Center. Those rules are set f~rth ~
in OAR 952-001-0010 thro!Jgh OAR 952-001-
0090. You may obtain copies of the rules b:.? or;
...J.IE'''~ ~on'o' (!\Iote: the telep.hon,1 t r
n~~b;rfor the Oregon Utility Not~1illon
Center is 1-800-332-2344).
rJ.~~
SIGNATURE'
FOR OFFICE USE
--------------------------------------------------------------------------------
DATE OF APPLICATION: 1-(~ - <1 i
JOB 1I: qc:{))(p()
RECEIPT 1I: :3 / L/3!
ISSUED BY:
$/(".r(J
-KuJ
TOTAL AMOUNT COLLECTED:
--------------------------------------------------------------------------------
"