HomeMy WebLinkAboutPermit Plumbing 1992-9-21
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: ~ t!f S-O U Cot Ie B yo L-- ~
Assessors Map If: 1?"e:><"~S'--Y"'<. Tax Lot #: e>1/6tt:'o
Owner: C L~: (' ~ (;) vrcJ 0 €' S L- ~. V
Address: r; 95'0 81. ~ e..- /3~ {.-(., Phone II: 7 ~~-'S-~(S ~
City :~J" ~ ~ ~ ':I''';~ State: 0 ~ ~ Cf c:s ~ Zip: q 7"1-/. I'
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: {?1d'H"E~
Address: Phone #:
City:
State:
~ip:
Construction Contractors Registration II:
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
~}j}u/ 0. ~'\
Signatuj?' .
9-2/....92-
Date
FOR OFFICE USE
Receipt II:
L, 'J. u-I
Issued By:
Job #: <t72~'26
~Jt8e
Date of Application:
~"'2/-92
Total Amount Collected:
l~./~
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INFORwlATION NOTICE TO PROPERTY OvvNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
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NOTE: -0T.~,i$:ltlfQ~r:lation ~v~t~c!=Uo\gq)pe~y Owners About Construction Respon~Jbiliti.Ef~01
. v.:as develop~.d by th~ Constructio~ Contrac\ors Board in accordance with ORS ~QJ~~~15X0>.:t,
~P~~~}LCLRY't~e 198.9-,--()[~gg~ ~~g~!9tw~e. : /::;,,',., ('.;:.J:': ::'.::'\
I j."('/~; i n.~_. _' '..r;.')";;
If'yo~~a'~~~:ciih~ggs YOtlr-own-cbhtikctar~tor:Cdrr~ructla new home or make a sUbstan~~~;~{I;n~~b~~~i~t"io an
existing struc~r~:r~9,;u~~,ap.B~e.;'en;, ~~ny problems by! being aware of the following resp'bQ~i~i.ljti~~;a~(;Vareas
--of-concern;--' _.Ul"" ......,v _"v. ,'"'/0 1,0 ,_..J "",,-.-,J'Y
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EMPLOYER RESPONSIBILI"EIES~v.J~€lJ~~:;jC<,::.'" ~~!1jr~~S~T ':?Gl~j':..? ',~>:'
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction roFiinY~ro\iemeM:j~f a':~e'siCleIiti'~r stfuctHr.~,~;yo'lJ.wfllf~ih most 'iri'sfalic&s, ~be~fuled to be an
"employer' '~~rfQ1th~3heopie:Y6.ufhwe"'wiI):HiP!emplc)y~~s;i.: As:the employer;:you 'Mu~(6brnpiy.,^,itf:l.the following:
..c1s1a BlnT .bau:.;::;: (:;d ,-,;3;; Xi':" 2:"j gn,blHi:J 2'1," 91~,(':;.' '.-::;, '~:1 ,;-; t.::dtj:'.; :,)t o. ' ,.~.:~
oregon's~j!~BM8iQ~~,Ta,~l~w.~~Xs;ag;~ryY~J~~~;~~.y~p;:~U~~{\.J!ttth61~ :r~~9~~. tix~~~f~nr iem;Bl~yee wages at
the ti me ~r11l?'oy,ee~_,a[~.'p.!ii9'~ .yOu \yiir;B~~J[a'D)~j~nJi~(~ifp~~:~e)#s:eveii~i!, yoU.~~~~t~adu~lIy' withhold the
tax from you'': I e'rrl pIOyees:" ~F6r' more' i'nformat'i6'ri; . cail' the -'Orego,,"'Departi:!:jer,ii Qffl'~ev.~r:l u~e~at; 378-3390.
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.rJ-:> At' d ~~~""- '_e.,." C'..... ..,. .. "'''r:d t~..:_, br ",,, "':,e' -:,' .\"'''-~ r'''''~ l"j ,";.;
Unemployment InsU'ra~ge Ta~? AsvMri'~nilproy~r,;Y8ul are'r~qu'iPed'to-p~y:"a:li~f)(fdr\.ine;mplbyn;eiit ihsurance
purposes on the wages of ~n'lt:~Bleye~~~B1GWcmOl~ti~!~0!;,il?&~~9~;.>San~t~~ 9~,~Qqn)~-'RP!oyn:i~Jl(~isi9n DHR
at 378-3224. . , ' .
""I:'\? ",' C'1'I'"., ;;;1 r-'-:~ y; ",..'t"'B""i'lO" """':~"'!I'i^"""C.\~ ~ ~~ .~,;..i'"::,,, Yo" 1fT: I t?r'~ br""'V~i!:'bn!J I I __...i..J C'
:.J J_ c;, :::I..:.. J. J ..._ ,~..... .! .,#.v d.. v 1.l;,,;fJ....,fJ....LI~ '1...:..) C.AJ ,.~.\::::"... ...~ ..d.l .__.,. ..v.).G _ _/__ . ~
Norkers' Compensation Insurance: AS.~0i~JJilPJQY~~,:Y9Y al:e.:.$ypj~:CM9.:.the;mr:egC51}; Workers' C'ompensation
Law, and must obtain workers' c-ol11pensation insurance for your employees. If you fail to obtain workers'
com p,eosationj ns,u r:anc.e,_y-ou_may_be_5u bj.ecUo_penalties .and; wi 11~b'e:;1 iable"for'alt cJai rm~ costsJf 6ne~of you r
employees is injured on the job. For more information, call the Work~rs' ~~mpensation Division DIF at 373-7434.
. _ _ 'le::lr.';~,Yi r!cl,S:}ZI:';:":~ '\:'i;J6'itnOJ
U.S, Internal Revel")ue Seryice: As an employer, you must withhold federal ilJcoJTIe ~a.~ from employees' wages.
You wilFbe'.;liable fonhe.taxi.pa~7tigRt~e{r~'ri iF~ll1f'jdilrnit';a618ally"wlthH6iihh'E{t~i' 'For ;more information, call
the Internal Revenug'j~~r\'Fd&J~f229~3g"60~:1~..m2no~ erG f:J'W DSleJ8i~el z, fBI,;iTi ?'iL~;
fJO
OTHER RESPONSIBILITIES AND AREAS OF CO~9.~tl:~~~:) 12'.S: 7~: 1":'0;:' \!r.; ::~ ~!h"J : ~~. E . E
,,;od(3,CorppJ!?f:lpe::;J.\s HL~,p@r,fJ2i~ ,~9J.RJ~r;~f,%!tli~.:P\~Rj~,c.!llIYPM&lr~.~f?.?pqQ,siRI~tQr !~~\~p.l\(!ng any failure to meet
cod~" r~q I! i!'~m~nt~b t.b..q.t;:r:rl~Y:J~~,: QrgygN:tQ ;YOl:J r~:?tte~ti.Qn:thrpl!lg,bd n$PElPJjpn.s;)~ '-i~.::
;]"i.:10c 31ojJ.2..,....~:~~:.:. ~':~)i!~~.t:.8~~:.) S~.:~ j~j-~vJ ~~:;~~~3:J31 ai o:fw~J '-l::;j.o"jl~{G8 s rlti'!t! )'OB11nO:l
Liability~and~Rrdper;tY :Dam,age' ilnsurance~. :Contaet.yoOr!in'sojance\ageA't:toTs'ee :if,'.ydu'chave adeq uate i nsu rance
coverage for accidents and omissions such as falling tools, paint overspifay,fwatEfl: Elarnage from pipe punc-
tures, fire, or work that must be re-done.
~]0')~''''rt~~~,}-;",;~, . '~~/:C,)"1 ~_>,^."~ ~ \~",.:;~. (:tl~,:r3 ~'~olr~~g) 88 f~.:0~~f2:C2;~&q~:~ s"~C!c~~ o:~(! ;.(rj-~~' \f~~~.~--':,)~ :~(': :':0::~ ~
Ti m~;:t9"($u p~(yisg':E inploy~es..:~ ::Mglk~;:9.4[eJY.Q1;I:;1:1~~V~c"~I;IUtcleQhtll]~TI t9 @!J RJ~Jyi~'e: Y9JJ.r =~IT:IpJ9y~e~J?1fr
,"'TU1J(r)~ c~c:g blfrt;O CIi2':::J~8il
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough~in a~d fini~..~.,trad:s;and to notify building Offici~~ ~t th~U:i~pr~pri~t~\- t~~,~ 5.9" th~y,.can perform
the reqUlred-lnspeotlons. '--'- _ _ ___ __._. ___,.,.., ,.,_~ __ .......,..,..\_........ . _~"._ '.
2.i:;C' , . ,,;:y::'qA ~~!.:-:' '.~ \"\':';~"-;'.';'..Ji '
If you have additional questions, write to: Construction Contractors Board 1
700 Summer S1. NE Suite 300
Salem~ o Fr-973 f'och 151" r.;,~O~) :::". ~";. !i~~;-~~:~;~~'~
.\ .v L. . __v
Phone 503-378-4621
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