HomeMy WebLinkAboutPermit Backflow Test 1999-6-11
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SPRINGFIELD
NOTICE:
THIS PERMIT SHALL EXPIRE IFTHE WORK
A!JTHORIZED U~D ~HI~ PFRMrr L'i:.Nm,
COMMENCE.BAJ PREVENTIOl'l' 'lTh'VICE PERMIT APPLICATION
U U ANDOf'(fifrfiC0l? SPRINGFIELD
ANY 180 DAY PERIOD, BUILDING SAFETY DIVISION
225 FIFTH STREET
SPRINGFIELD OR 97477
OeFICE: 726-3759
INSPECTION LINE: 726-3769
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JOB LOCATION: J355 'j)LEfI"SA..J r SQ..(.A.f
, ASSESSORS MAP l!: /7 fJ ') ZS 3 "2-
OIINER: 30 f),q U In -S: fi / ffi:': f'
ADDRESS: /355 ~1'I;)>'I,.,Jr ::s:rRJ-L-T
CITY: 5\>R.ANL..~'C:-L ()
STATE:
TAX LOT #: tJ7'-/oo
PHONE l!:
-;LJfo-(P708,
ZIP: 97<-/T7
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BACKFLOV PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADMIN. FEE) ~ $16.20
BY SIGNING THIS PERMIT/APPLICATION, I AGREE TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVENTION DEVICE HAS BEEN INSTALLED AND IS VISIBLE FOR INSPECTION
(726-3769). I ALSO STATE TIIAT ALL INFORMATION ON THIS PERMIT/APPLICATION IS
~~CT. ( .
,.~J)J" .,eLL
CONTRACTOR:
,J ),Ll
ADDRESS:
CITY:
STATE:
CONSTRUCTION CONTRACTORS REGISTRATION #:
FOR OFFICE USE
ATTEN1IUI~.v,,,~V" 'dW ''''4ulIt;o YU",
1....II....ul....I........3....'\.~....... ..........- ---- - 1-.'
., . - --...-..._..,.I...__.....::-:I.........ll"t~j
NQ,tjfir.~ioAi.Center. Those rule~ ii, e S.:lt tort,
:1~~~5~:eC~ :::-C~~ ';'IV"'~II CMn ;:1;.J2.U01
0090. You may obtaiz'I;p~les of tht: I ules b'
"d,iilli:! Ill" ""'ll"'. (Note: me lelepnone: '
numbe.r for tl:rsC~R!lSI:i Utilitv Notification
Genter is 1-AOO-332-2344).
Co~ II .'icr
DAtE
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DATE OF APPLICATION: t /1/ if
RECEIPT II: {F3 'IL/ (7 ISSUED BY:
TOTAL AMOUNT COLLECTED:
I b -2-'0
d NJOB l!: 99d7f (
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