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HomeMy WebLinkAboutPermit Backflow Test 1999-6-25 . Al\I::\'Illv"'--" the reyv"~" . lollow rules adoPte~::se rules are set 100;:. , 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 . JOB LOCATION:C/~:& iJ/J f' YI1Painf () 1.1 J.':::; /:// .' ASSESSORS MAP 1I: 176 3 ~'1 2- 'J..- TAX LOT #: 00717 "/J " r- 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 , 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: ,. ; '~, 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/ Ib.!..-o TOTAL AMOUNT COLLECTED: ------------------------------------------------------------~--------------------