HomeMy WebLinkAboutPermit Backflow Test 1999-6-10
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SPRINCFIELD
NOTICE:
THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDER THIS PERMIT IS NOT
COMME. NCEDORISM~B~NTION DEVICE PERMIT APPLICATION
. ,v'CITY OF SPRINGFIELD
ANY 180 DAY PERIOD. BUILDING. SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPECTION LINE: 726-3769
Job Location: \G,("O ~'~({\"i
Assessors Map II: 17031)2/
Owner: LI~V\~
\~()., ~Ii~
.gO..-\w:l.l-..M State: ~
Ii 1\
Backflow Permit is $15.00 + $0.75 State Surcharge-\ AS
Tax Lot H:
03 rc)o
Address:
Phone H:
City:
Zip:, 9J'1')
Q)Cd,) f. ((...V:>
Contractor: ~~C \~~~
Address:' l"5I'-1. Ct:IS'--"'""i QJ ti.~o<' Phone H: $'"'-tl
City: ,j ~~ . State: ~
Construction Contractors Registration II: ~_O '-1. ~
Zip:
~ e.(P-'i \.t 43
~1'-1.-<J\
"'licro
Expires:
By signing this permit/appl icatiorT\nE~re~:<i!O"(cliW\ffO,quAr~S-vns,p.~ction once the
backflow prevention device has beNlIOi'n!i-liall~le!lPlrrf'dblishry~~IJ\l1!LIfO~Y inspection
(726-3769). I also state that al1l~ti~I(i:Wmltl1ilcjrr'onOtfiisleap.lllli'fat(i'O~/permit is
correct. in OAR 952-001-0010 through O:A:R 952-001-
0090, You may obtain copies of the rules by
a=alllng the center. (Note: the telephone
r ^ ^ \ _ r /' \\ ),. . n mb for . gon Utility Notificatio[! J ;} C;
V V ~ \.1.....J<r ~ d 1-800,-332-2344). C I..t C) I'
Signature Uate
FOR OFFICE USE
Date of Application: C, / (0/74 .
Receipt H: D )4'$ g-3 Issued By:
Job H: tf7() 7fd
. aJ /JJ
Total Amount Collected:
Ib- l-o
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