HomeMy WebLinkAboutPermit Backflow Test 1999-1-26
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ATTENTION:Oregon :aw r'i.qulle~ you to
follow rules adopted by the Oregon Utility
Notification Center. Those rules are set forth, '
in OAR 952-001-0010 through OAR 952-001-
0090 You may obtM~@Y o\'lffiYHNUOlj DEVICE PERMIT APPLICATION
. t (Note' the te,ed ~ OF SPRINGFIELD
calling the cen er. '. . R ..= SAFETY DIVISION
number for the Oregon Utrhty No lUll"
225 FIFTH' f.Tlfi!~'Jis 1-800-332-2344). OFFICE: 726-3759
SPRINGFIE::.D OR 97477 INSPECTION i:INE: 726-,3769
:::-::::~:::~--~~--7'=;-~:~~-----------------------------------
ASSESSORS MAP D: 17 ~ < "), ~ q ~ .TAX LOT D: tJ'I6tJO
OIlNER: .: :r;;., 77:L..( ""'-
;(f7n ffi~~ s
ADDRESS:
CITY: :s' /?i?",~..t? -c. U::)
,
STATE:
PHONE D:
B .-f'~
ZIP:
BACKFLOY PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) = $16.20
c:;ONTR.Ap'l'O!): J-/L<-oVT:;..f' Tv('/P/~Ah'A' ~ ..(A~,,,c:J.sc.4A 'J::',vc:,
.'
ADDRESS: ::J,'l:J..;;U~ ""//,-;"",,,6:.-f'A./ .(-?~.""- .PHONE D: 9J..F-S,;;,/J-
CITY: I/~ /lI.;:T;:<J.
STATE: ~~
ZIP: 9'?Pa'-7
.EXPIRES: Y-3~-9?
CONSTRUCTION CONTRACTORS REGISTRATION D: J /3 ?;;1..
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOY PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE THAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
CORRECT.
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NOTICE:
THIS PERMIT SHALL EXPIRE IF THE' WORK
)-::<t:'-9?
DATE
^ 1'.,..,.,.........__.... ... ____
--,-,..- ., .~. ,,~~v V",IJl:;n I no" t'tNMI (IS NOT
COMMENCED OR IS ABANDONED FOR
A~!V if' "-/ v prRIOn .
FOR OFFICE USE
--------~'-----------------------------------------------------------------------
DATE OF /;PPLICATION: /(').(,1'1'1
RECEIPT I': () > 2.' 7 Lf ISSUED BY:
J UJ jl: '13096X'
TOTAL AMOUNT COLLECTED:
1 t. ;z..t>
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