HomeMy WebLinkAboutPermit Backflow Test 1999-6-25
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Notilication Center. ugh OAR 952- -
. OAR952_001-0010thro. sol\heruleSbY . . .
In u may obtain Cople, Ale\;1hone
0090il~09 the center. tNotlJe:BlJ(cW,\\lla~VENTION DEVICE PERMIT APPLICATION
. ca I the Oregon t\lllY I' CITY OF SPRINGFIELD
number6~~teris 1_800-332-2344). BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
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JOB LOCATION:C/~:& iJ/J f' YI1Painf () 1.1 J.':::; /://
.' ASSESSORS MAP 1I: 176 3 ~'1 2- 'J..- TAX LOT #: 00717
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OIlNER. j:p rri,< 'i- I a ,I" , "- ,.J I",", f;fb JA'
ADDRESS: cJ h f ;p~ 1( J11 Ph .~f'd.././).s . PHONE #: "/.' ~c:: -0 ~ (J 9'
CITY: _.c; /Oil-f. STATE: f: ~\? ZIP: 9'711-'77
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BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) a $16.20
CONTRACTOR: (() // / fA e tr'
ADDRESS: 1~ % 1)/0_ P 7dJ (V r7 /f)..d..I./ ) <:::; ~ PHONE #:
CITY: "5'"1" lr-/ STATE: NIP \
CONSTRUCTION CONTRACTORS REGISTRATION 1I:
73":; -/) t:./J 9
ZIP: 9'741/,7
EXPIRES:
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BY SIGNING THIS PERMIT/APPLICATION, I ~~:CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN IN~~~M~tm~miflFFiH€~'il13cTION
~6~Eg~9). I ALSO STATE THAT ALL INF AUTHORlZtDUfJ6ERf~lbJo?ERMtf~6lIlION IS
COMMENCED OR IS ABANDONED FOR
~ ANY 180 DAY PERIOD.
~",,; /J ) IV, /~.---/ ~ /4.5/ yC:;
)>l{~N~E ; ""-".. /. DATE I' t ' .
FOR OFFICE USE
DATE OF APPLICATION: G/2s/ ff /j .. /J JOB #: 99of'79
RECEIPT #: 03 '1~2-q ISSU.ED BY:.d!/ tJM/
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TOTAL AMOUNT COLLECTED:
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