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(7- J� Mailing Address Street Address FORLITYUSEONLY <br /> To P.O.Box 66 2750 Kelly Parkway Date Received: 5 /L `/ 7 <br /> ,gro. Crystal Bay,MN 55323 Orono,MN 55356 Permit# 2.o/ 7 IG' <br /> Is y Fs d Phone:952-249-4600 Fax:952-249-4616 Approved By: 1.(01:12,C, <br /> k stiOtt Website: www.ci.orono.mn.us Date Issued:l'sb -((D. ( I <br /> CITY OF ORONO - BACKFLOW PREVENTER TESTING PERMIT C� •�� d <br /> PERMIT CODES: City of Orono, Minnesota State Plumbing Code, Backflow Device Only <br /> THIS APPLICATION IS FOR TESTING AND REPAIR OF EXISTING BACKF OW PREVENTION DEVICES <br /> 5 <br /> Job Site Address: ,.7 r 0 old Ci yjr'--, 1300(0( R Ul <br /> Owner: j VY. '16c,k Telephone Number:J95 — H1 a— 3457 <br /> Mailing Address: 55o old crus-�.t 0 ,o( t� A) <br /> City: 447' oral / Zip: 553J`C.2 �}C !/ �Q <br /> Contractor:C-i 1 Y V iCa ?l u.Wl� � Telephone Number "/Oa' �( 3— .7'9 ' <br /> Contact Person: �'qq (fi [ 164) Li nse# PC lO' '1 3 <br /> Mailing Address l U 06'- B W19f- W�� *t �(V , ?,Q, 0K. 1562 <br /> WATER SUPPLY: Lake ❑ Well ❑ CityM <br /> BACKFLOW DEVICE: AVB ❑ PVB g Quantity I <br /> COMMERCIAL KRESIDENTIAL ❑ <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 /> 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) $ I'i.00 <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 arue and correct. <br /> Applicant:�-� Date: <br /> 6—Mg-- <br /> Page <br /> — MPage 1 <br />