HomeMy WebLinkAboutPermit Backflow Test 1998-12-3
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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK .
AUTHORIZED UNDER D~I:'k~E~-&,IU~~BJl'ION DEVICE PERHIT APPLICATIO::
COMMENCED OR IS ABANDONED FOR CITY OF SPRINGFIELD '
, Y pF.RIOn BUILDING SAFETY DIVISION
ANY 1RonA . '
225 FIFTH STREET "F~ICE: 726-3759
SPRINGFIE::.D OR 97477 INSPECTICi LINE: 726,,3769
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" ASSESSORS HA} I: ~ 7 oj .2:5 4- L/ _TAX LOT f. [/0 ()
OIINER: f?J/;;;y(t,~_le....- dr,.,~f ::D./L-,
ADDRESS:~3S- ~)(LrcP Av, PHONE I: 3Y~-'7,;)(j.:>
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CITY:
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Cu ~. (j;[, <<J7 L/O ( STATE:
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ZIP:
BACKFLOIl PERHIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADI:N. FEE) a $16.20
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CONTRllpTO!'j: S L, T,
0' ADDRESS:" /~/j ~;,,/,
CITY: <;~
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CONSTRUCTION CONTRACTORS REGISTRATION D:
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d;,,_ e iA..r1Le~ . W .t,l'HONE I:
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7'-1'1- -71 ~r
ZIP:CrJ 1(77
EXPIRES:
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BY SIGNING THIS PERHIT/APPLICATION, I AG~D~OR AN IN:;?!>CTION ONCE TilE
BACKFLOV PREVENTION DEVICE HAS BEEN IN~,!,~ ~illYJ!e<ltjl{etNIlPEl!:TION
(726-3769). I ALSO STATE TIIAT ALL INF%M ~gc:lili~rl't.!l.~U.I6~ON IS
CORRECT. , on enter,lhose rules are set forth
In OAR 952-001-0010 through OAR 952-001-
0090, ,You may obtain copies of the rules by ,
calling the cent~r, (Note: the telephone .
numberforthe Oregon Utility NS)Jification ~i' QeJ' '
Center is 1'800-332-.2,~' .? - / 7 I.
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FOR OFFICE USE
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DATE OF /;PPLICATIONI-U/l::- /q<{ /) .... JO:; 6: o/f{f1&'s'
RECEIPT h tJ ') v ~ ~SSUED BY: )"'\ - /1Ii 1.1 ~
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TOTAL AHCIUNT COLLECTED:
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