HomeMy WebLinkAboutPermit Backflow Test 1998-9-22
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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDER THIS PERMIT IS NOT '
COMMENCED OR I~ACKFl.mlNl'RE.VEmON DEVICE PERMIT APPLICATION
~ABANUOI EDFCijtTY OF SPRINGFIELD
ANY 1BQ DAY PERIOD, BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OFFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: ,.8,'7 (P R I U Elc..
." ASSESSORS MAP ll: 1105'2- >'/3
OI/NER:MI'Z..... ~fh II poi-
ADDRESS: 13 7 ({; /2..\ CJ c::: Ie \0( J\jO LL wAy PHONE ll:
CITY: 41~..... fJeJJ STATE: (()Vf--
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l< l'icJ L- L.., IAJ f1- Y
TAX LOT ll: I
(jlf'foo
12..4> - q 7Cf1
ZIP: 914-77
BACKFLOII I'ERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
CONTRACTOR: TZ-IT / tV '3 ~'7 5r/'2-<4 ~ f La4~~ eo'IJ~.
ADDRESS:. :1..4-"70 dlPrtC C1rtOVf PV2- PHONE ll: 5'4-1 4les-4-:>rp,o
CITY: E.-V\....~ STATE: (C)VL ZIP: Q14-0:7
CONSTRUCTION ~ONTRACTORS REGISTRATION ll: to ? & S-- EXPIRES: _ 4-/30/ q 1
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BY SIGNIN'; THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
~~~~:~~~9~~EV~Nr~~~ ~~Xi~ET~~~ ~~~I ~~~~I~~I~~~p~~~~~ib~O~s
CORRECT. o. ?JJ~8res alfo~fe8liy lfie OregonUiihty
NotificatIOn Center. Those rules are set forth
in OAR 952-001-001 0 through OAR 952-001-
0090. You may obtain copies of the rules by
calling the center. (Note: the telephone ~ q'A...
number for the Oregon Utility NotificallOR z.. .' U
,",,,,,,t,II IS ,-ouu.,,32-2344). DATE
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FOR OFFICE USE
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RECEIPT hi/ j ISSUED BY: ;0( O""'i
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TOTAL AMOUNT COLLECTED: It. tfi ,
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