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• ' Dec. 12. 2017 9:47AM �No. 4291 P. 2 <br /> , t ' , Jo 1 <br /> Mailing Address Street Address FOR CITY use ONLY <br /> scitfrP.O.Box 66 2750 Kelly Parkway Date Received; <br /> Crystal Bay,MN 55323 Orono,MN 55356 permie�f �C�7 " '`� <br /> '`y� Lt Phone:952-249-4600 Fax:952.249-4616 Approved ay: �'') <br /> .t C', <br /> Website: Www.ci.orono.mn.us Date Issued: 1 L /5T t/7 <br /> • <br /> CITY OF ORONO — BACKFLOW PREVENTER TESTING PERMIT <br /> PERMIT CODES:City of Orono, Minnesota State Plumbing Code,Backflow Device Only <br /> t� iN S � N7p , !+raiMI VAGOV`.rr ,m uA t a.&,,>a ."i:..Tsonrt14RV';n: l , ,ari ',), -hE ,•.b: t t .,it if0, ,,, <br /> Job Site Address:SCib, lcL Q[ (� (3Q <br /> Owner: ()>'C) J( C��' 1.`-�` I 0 elephhoone Number:c Q • 4 i-i"'I ' `6 9 <br /> Mailing Address: d f) 1; ,18. C.q 1iS�c& V)--;o. . K> ' <br /> City: �A'lf?L �F' Ail Zip:Zip: , �e--•)Ln .. <br /> Contractor. i► a •e.° 0 i : /AI L.d .1 •lephone Number 0]I' 4f,,9-• ` `(s'(1) <br /> Contact Person: 1 P- \1 y'V ,ly, '4 I� V, License# PC L I 1 <br /> Mailing Address gLI- '3- 6.-,v--6, e' ✓1L.11Cuj A-ve Dv e__---,--)- Lei / y) 5La.3 <br /> WATER SUPPLY: Lake❑ Well❑ City❑n <br /> BACKFLOW DEVICE: AVB❑ PVB❑ Quantity .� <br /> COMMERCIAL 1' RESIDENTIAL ❑ <br /> GENERAL INFORMATION <br /> 1. All testing reports shall be submitted to City Hall after work has been completed. <br /> 2. Provide the following information on all reports: • <br /> a. Job address,Owner/Occupant. <br /> b. Testing person's name,certification number. <br /> c. Company name,address, phone and contact person. <br /> d. Description of work:test,repair or replacement.(New installation requires a separate permit) <br /> e. Location of device(s)and system being served by the backflow preventer(s). <br /> f. Make,Model,Size,and Serial Number of each device. <br /> g. Testing cycle year,testing date and or overhaul date. <br /> h. Testing results and comments. <br /> I. Report must be signed by person doing the work. <br /> • <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee: $ 10.00 <br /> 2. State Surcharge: $ 1.00 <br /> 3. Mail-In Fee: $ 2.00 <br /> 4. TOTAL PERMIT FEE(Add lines 1-3 above) $ <br /> The undersigned hereby applies to the City of issuance of a Backflow Testing Permit,agrees to do all work in strict <br /> accordance with the ordinances of the City and State regulations,and certifies that all statements made on this <br /> application are complete,true and correct. <br /> Applicant: Date: <br /> Page 1 <br />