HomeMy WebLinkAboutPermit Backflow Test 1999-6-28
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SPRINGFIELD
ATTENTION:Oregoflldw .9qulref )lo~ t ;
follow rules adopted by the Oregon Utility
NotificatiDn Center. Those rules are :;et forth
in OAR 952-001-0010 throuah OAR 952-001- ,
0090 Y U may obtal.rBACKELOM t:l:'!J.~Y:~.O~ DEVICE PERMIT APPLICATION
. 0 , UVIM~ v ~Y OF SPRINGFIELD
calling the center. (NDte:t~e tele\\ur. NG SAFETY DIVISION
number for the Oregon Utility NDtlil...d I
225 FIFT!PrSTREET-flon-332-?344). Ol'FICE: 726-3759
SPRINGFIELD OR 97477 INSPECTION LINE: 726-3769
JOB LOCATION:
" ASSESSORS MAP U:
OIINER: 'Sc.t<'> lJ"
ADDRESS: \ \ J (..
CITY: 5r~\J
I \ :X.. G,..-L, 1l.J"l.'\ I~~ r
/7632-2..Q'L
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TAX LOT U: 62'10/
STATE: <DP
PHONE U: 3<ll,I-.).l '7'1
ZIP: q]<f77
BACKFLOW PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: \~ ?\\',^"\)\\"'l'\.~r\\,,l--<\
ADDRESS: \/0'-\ U).."d. ~~ rb Be..- J.lqo'7 PHONE U: ?(f<-{-q~91
CITY: tl "1'P'o.R- STATE: ~O ZIP: q7~o1.-
CONSTRUCTION CONTRACTORS REGISTRATIONN~ IIdf7:h EXPIRES: ~/ 10/'1<1
BY SIGNING THIS PERMIT/APPLICATION, ITtJl~~~IF~~~~~~~~~~ ONCE THE
BACKFLOW PREVENTION DEVICE HAS BEEN ~~~~RV~~BBr'f.~Rv1RSPECTION
(726-3769). I ALSO STATE THAT ALL I~m!lJ.\!:ll"\QlAS\.ANflOOfi~,rmICATION IS
CORRECT. ANY 180 DAY PERIOD. .
SIC
DA';'r; r0 rkv
FOR OFFICE USE
DATE OF APPLICATION:
RECEIPT U: 6 S If b '3 3
TOTAL AMOUNT COLLECTED:
{, /z.i/ '7 f
ISSUED BY:
1 /J Jon U: 7'l()o 7'-1
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