HomeMy WebLinkAboutPermit Backflow Test 1999-8-4
.
.
ATIENT/ON:OregOfl jaw requires you to
fnllnu.I r';' I...,...,....J__._ _". , _
.
SPRINGFIELD
f\ ~oit-U01-001 0 through OAR 952-001:
0090. .You may obtain copies of the rules by
calling the center. (Note: the telephone
number for the Oregon Utility Notification
Center is l-ROO-3i1ACKPIIOII PREVENTION DBVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIFTH STREET OFFICE: 126-3159
SPRINGFIELD OR 91411 INSPECTION LINE: 126-3769
:::-::~:::~---~::---~~:~-;:~---6~~d~---7;~~-;;:;---~~~~-;~~-;---~
\ll()~~ / TAX LOT #: n\\ (1,')
to{v\..
ASSESSORS HAP #:
OIlNER: ~ +'<-lfE.
ADDRESS: 1'103 I.A-frJ-.r 6 i.t. c:{o~
CITY: <:7PI,1rv; k<~c:f
~
~h ,PHONE I: 7'11-'7$"'6
STATE: c~ ZIP: 17<.(77
BACKFLOII PERHIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADHIN.
CONTRACTOR: f}tPf?E:ef..! EnU<4;fC-E..MteHf
I .
ADDRESS: P,o IJOk 'C:/I't~S
d"o.
FEE) D $16.20
I lq" '::P
PHONE t:
(P33~706, >
ZIP: 9 ,~.,</
.EXPlRES: ~/~ ~ ",c..' d
CITY: ~~ STATE: ~
CONSTRUCTION CONTRACTORS REGISTRATION I: (Plio 5
BY SIGNING THIS PERHIT/APPLlCATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
NOTICE:
~SPERMITSHAllEXP'REIFTHEWORk '7 . '7 i
AU I HORIZED UNDERn';IS PERMIT I~m-
COMMENCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
FOR OFFICE USE
~::-:;~:::~ri~:::-::--~\N)::T[qfDwr
TOTAL AHOUNT COLLECTED: \ \ 0 .~) "
5IGNffir
tc.--
--------------------------------------------------------------------------------