HomeMy WebLinkAboutPermit Backflow Test 1999-1-25
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ATTENTIO :Ure ~ Oregon Utility
follow rules adoPte1h:~rules are set forth
BACKFLOV PREVENTION ~~~'Plfgc#trf:>;!,6i\!!1I~AR 952-001-
CITY OF:~* t;>,tain copies of the rules by
BUILDING S~m,y lfl-!h ~ter (Note: the telephone
calling t e c ' Utility Notification
225 FIFTH STREET number for the, Oregon '_23lf~+CE: 726-3759
SPRINGFIE:,.D OR 97477 CenteflS 1rNS~E'WIC'1 LINE: 726..3769
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JOB LOCATION: 5/~<1 tYdk#t:T?
.' ASSESSORS MAP ft: /1rx 222m /
OIINER: Eyht7;1 '#//t:'H
ADDRESS: .., /S-eJ 6t/Tt'U/7
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,TAX LOT 1': ~ {j () ()
~.r:' ,PHONE ft: 7'Z-~-6t?//,
STATE~~Q;)CE: -__ZIp.:fZ~77
- THIS PERMII :;r1I\LL 1:^"lnl- ,,. I HE ,,-,...
.. 'T' '''qI7E~ I '~IDJ=R THIS PERMIT IS NOT
BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCIIARGE-) +' $.45 (ADI IN. FEE)FDR$l6.20
C21,;i.'U:C::C Oq IS ABANDO~.tu U
C;ONTRA,C'I'Ol'j: 11/ 4f7'/' Fka/ 5;-t!!-C//d/Wr'S.v PER'OD
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ADDRESS: 9'/ Z J/ 5"1- PIIONE ft:,? %-b Y2--?
CITY:---i'J'7r<f4uth-'e/d STATE: C'r ZIpj?:7f77 .
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CONSTRUCTION CONTRACTORS REGISTRATION ft: /2- 6' t77J' r,XpIRES: /r-S'-~
CITY:
BY SIGNING TillS PERMIT/APPLICATION, I AGREE TO CALL FOR AN IN::?ECTION ONCE TilE
BACKFLOV PREVENTION DEVICE liAS BEEN INSTALLED AND IS VISIBLE 'OR INSPECTION
(726-3769), I ALSO STATE TIIAT ALL INFORMATION ON TillS PERMIT. ,iPPLICATION IS
CORRECT,
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FOR OFFICE USE
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DATE OF /;PPLICATION: { / ~J /f /
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RECEIPT I': IJ '5 2..' ~ 4 ISSUED BY:
. j} JO:, #: qq 0/03
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TOTAL AMOUNT COLLECTED:
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