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HomeMy WebLinkAboutPermit Backflow Test 1998-9-22 . . 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 ---------.----------------------------------------------------------------------- , 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-- -, ./ 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 ~Rf?- 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 ~ FOR OFFICE USE ::~:-::-:,~~::::~o::;~/-~-~-il:-;lfi----------:-~-~--::::-:~--(YtO-2(~-- RECEIPT hi/ j ISSUED BY: ;0( O""'i l TOTAL AMOUNT COLLECTED: It. tfi , ---------,----------------------------------------------------------------------- , ""'-, ',/