HomeMy WebLinkAboutPermit Backflow Test 1999-6-10
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SPRINGFIELD
NOTICE: .
THIS PERMIT SHALL EXPIRE IF THE WORK
AUiHORIZEDUNDERT~b1Jjf~WNTION DEVICE PERMIT APPLICATION
COMMENCED OR IOSDABANDONEDFORBUI m N~~ S~~~~~G6~ ~i~ I ON
ANY 180 DAY PERI .
225 Fifth Street Office: 726-3759.
Springfield, Oregon 97477 INSPECTION LINE: 726-3769
Job Location: \ <.. L. \ Ra~\"j
Assessors Map": /70 ~ lS2 J
Owner: Ye-r-do-
Address: \(, '--1\~I,'4
City: ?~~ ~~
Tax Lot": 0 s/oo
Phone U:
I Y L.,- I ~S -,
Zip: 9J\1l")
State: &{'
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Backflow Permit is $15.00 + $0.75 State Surcharge -t A";S(~9oJ
Contractor: ~~ (>-""0~lh-- ~'
Address: \S,'-1 ~ ~ ~~O") Phone U:
City: Ev'i"'-~ State: csv-
~ 1C,.z..O
Constru~tion Contractors Registration U: 4>04'i
Co tc., -'1Y C, J
Zip: o,J"-LD/
Expires: '-i/t\o.
'. Wr~.
Signatur~ '. ~ ---~
By signing this permitlapplication, I a.9.ree j;o call,for ,a!:,. in!\R,ec~ion once the
backflow prevention device has been in'St1iEjif~(iP~'d'r'iisvlv'i!s"iD;i\J\rfOrv~~n'~gection
(726-3769). I also state that an in~~ni'a~;laiF6'rrpt'f{WYa~p;-it,afi~ony,'B'!'l:,mit is
correct. Notification Center, ,nose; Ii.lles (lit! "eil or,
in OAR 952.001.0010 through OAR 952-001-
~_ 0090. You may obtain copies of the rules by
calling the center. (Note: the telephone
( number for the Oregon Utili:~~rllf4
, . ,-,emell:; ,.800.332. at'!f}'
FOR OFFICE USE
Issued By:
Job U:
cf IJJ
91 (j 7 7 If
Date of Application:
Receipt U: () 'St{~ g-q
~/fo/f'j ,
I
Total Amount Collected: / C. 2u