HomeMy WebLinkAboutPermit Plumbing 1993-6-4
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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:
,~()R (~L\0~r\ Q _ \j5\ J\' \ J-f .
Assessors Hap D: \8(j008, Q".8. Tax lot D: ()-=,~~
owner:.~D\ Q\ r (~() ffiffi \ e _~) ,
Address: -'jfJR.~f\t)t'f\f\(Lt\l~lliC\' Phone #: ~\-CJ~S. .
City: 1'\\\\)\ ~ (l,f\tuD ~ State: ~ f-V(\ Zip: qrj~
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Backflow Permit is $15.00 + $0.75 State Surcharge
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Contractor:
Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
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 al~o state that all information art this application/permit is
correct.
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Sfgna1:ure
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Date '
FOR OFFICE USE
Date of Appl icat ion: .J) .4-. go ~. Job #:
Receipt D: 9'7Al- ,ISSUe~y:~_)
Total Amount Collected: \~.~-) .
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Permit No: ~,J ) l( ) ( ~
Address: ~rP:) QQ) ~f}, -.;
Issued bS\.f)O_) oate:lO' ,q~
FOR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
Fill in ~PPlicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
1. I r J I own, reside in, or will reside in the completed structure.
2. II I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
3. A.I
I My general contractor is
Contractor registration number
I will instruet my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
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3. B. I ~/ I I will be my own general contractor.
I '\.. If I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. If I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
I hereby certify that the above information is correct and that I have read and understand
the Information Notice to Property Owners' about Construction Responsibilities on the
reverse side of this form. .I~ j ~
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I "Signature ('1fpeMt Applicant Dale . ,
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
, WHITE COPY TO ISSUING AGENCY PERMIT FILE
. PINK COpy TO APPLICANT
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.IN.FOR""~TIQN '.NOTICE TO' PRQP~RT,Y:' OWt.iERS'.'
.~,:~~~~T S;q.N~T.RUCTIONRESPONSIBILlTIES .'
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. NqrE,:.),.' c,. Thi~:'I'1fQrl1JatiQrJ N()tic~JtQ I?rQRerty, OwnersAbQutCo.n,structiQn Respohsibiliti.es.,:~L
",.vya$ d,e\l~'ope(fbYJbe OQnstructiQn CQntractbrs',BQard int,=lccQrdance with OR~7;Qf@?5(~)kt.., ~'\.
. i ,,/:. f_p?aS~'ed.,by.,'the..19J~9.oregon Legislature,,, ' .,.. < :'.. : :;:;:'~::~~;~;:I:~,:,,,i:'::;;,,,,", ''"
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r If you:'are actin'g'.as YQur Qwii"c6htractbr to. 'CQnstruct a new hQr;ne' or make Ci subs!Ci.n:ti~':.'ih-iPFQ~~.iJi:~nFto an
; e~istingstructur~, "YQu.,Gqn"piev~ntrriqny prQblems'by!being Ciware Qf. the'fQllowing r~spbrisibiiities~a,nd' areas
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EMPlOY'E'R'. RESPONSI 81 LiTIES: :i:.;~ '~i~;.~J:+~Yt;:' <:",c:
If you hire pe(SQrtsnQtregistered with'the Constn.iciiQ~ CQntr~cto(s.Board"i() do. labQrincQnstructing-or assisting,"
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, in .the co.nstr~~\L9'R: o~\i~~pr~)t~h:i'~'1t?Hl !es~qehtial)fr~c,t~re,:YQY~i~~I;I:,';,!n "m()st".ill~t~nce~,,'~f1~:.ruled to. be' an ~.
"empIQyer" .anq ffi'e pe6pl~:y6~ birit\Y11I;-Q~:,' ~~~hjpI9SWe.~r: As the 'employ~f, 'YQu:irlUst'~Qmpiy witfl;the fQllowing: ,
" ," ,.l ,~''',:.;,' :~"" '~.:' ,';-.',,/,':,,::/ .:)~~> :\:.1(0 ",',: ,':o~-:::",;: -: i~' ",:'" c"_',~,.1"~"/ ~~"1':,',:, ~,:.';:',: " . . . : '.
Ore~Qn's .VVi.t.tihQlq,i~g, Tax:~"a,v,V:; ;~~~ '~~~:7M~I\0Ye.r, 'Y8H::rnust wit~hHI~. 'in'9ROi.~\t~~~s~frp~'~:IJ.W!gy~~ wages at:,.
the time emplqy~~s an~ paid. ,You W!II:be,hable .fQr th~ ta~hpaymer.tts ever.qf yeu'donU act.uallywlthhQld the
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, tax from YQur emplQyees: '~QrmQre 'infQr~atiQn, .call ~he Oregon Dep~ljtl!T;\e!i! Qf;R~yen,y.~:}~t ~?8~3390.,
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, UnemplQyment Insurance Tax:' Asan'empioyer;~you aref req,uTred':tQ'p'ay a tax.for.unemployrjient" insurance
purpQses' 'Qn. ttiewages of all,e,~'pIQyees:\)FQrll1}o[e.il)fQrrDa'ti~n:,. ,call th~ 9r.~:gQn 'Erop'IQYTj~'it:.Q~vi~jOri.D~~,
. 'at,.378-3224. ' . ,.' ,,' " .. :.' .,:, '~. c,
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.WQrkers' CQnipensatiQn'-1dsurance:As ai:1 erTrployer;~YQlIare,:s(jbject tb~the OregQn)NQrkers' 9Qmp'ensatiQn '
Law, and'mllst obti:linworkers' CQmpensatiQn insurahc~. .fQr your, emplQyees. It. y~u (aHtQQb~ain'wQrkers'
compensation insurance, you may be'subject tQ.penaltiesand'wHi'beflia:ol~norj;a:1I C1aimcQsts'if'Qne Qf your
" employees is . ii1juretf on the jQb,., For mQre iAforniatiQr;J,' 9all, tt)e \.IVQr~~r~-"Cpmpen.sati9n, Oi\(ision' DIF at '373-7434,
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.u.S"lntenlql'Rev~.nl,J.~. Seryic~:, _~_~~.~rnptgy~r, 't9H!!!l:l.st ~i!~h<?tp.!_~c1e~~1 i'lco.llJ~ta~ !~9m employee~: ~ages.,
. YQU will be liable lo'r'.'f~.~r(~~.P!=lYro~P.r. ~y~~:if :Yo.~did:n',t~~Wall(yvi~lJ~g!,O t,het'\!a),(f:fp(m?r,e~infor;mation, ca!1
the Internal. Revehue' Service at 2'21:3'960: .u..., , . . :.:,>" '-. '" '''~:;.~. " .
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OTHER RES'PONSIBILI,TIES'ANDAREASOF CONC,ERN:., ;("'\'~'~' :. :...,.: . ,,:.. ' ~.
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Code C.Qmpliancer !"~slbe' permi!' I;iQI<l1er for'tlilis;project-" YQU ar~,resPQnsible fQr resQlving any failure t,!) r:rieet
cQde requi!~ments 'that. fT:lay b.a Ib~Qught to Y0!J.1r attentiQn:t.hrough .ihspe"CtiQns,,~;, :i.;:: ' '.' ,
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liapiliiy and:Rfdp~tty' bainage~ fnsuranc'e:;' ContaCt you(insur,ance 'agent 't6;seeif;Yol:J' have adequate ins'u'rance ",
c;:overagefor accidentsand'QmissiQn,s :suqh as falling tQb!S, paint QVerspfay,;;Water.:a~r.nagElff:Qni pipe punc.,
tu res , fire, or '4'iQrk th~t f!'ps.t. ~~ re':done~ . -" .,',
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Time"l6 Supervis~ :Employees: . Make :sure. YQ(f:'bave,'sl,lfficiel)~i'time: 'fQ supervise' YQur~~mpIQy'ees'. ."
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, Expertise: Make sureYQu ~ave'the exp'ertise to' act as your own ':g!3neralcQntractor, tQcQQrdinatethe~6rk
. Qf r6ugh~in and~:fini~h. trt,=lde~j ,a:ndtqnQfity building Qfficia'~ at thei apprQpriate. times/so., they. can ,perform. :,
.' the requireq::iri~ped(~ns.: ..., ~i./(~ ':', .~: :"'. ~ ...:t"":.:":':\;:~, :;~~. ~>':'. ',,~'~', \~~"j10L"'.)I,g \ \ .'- ~',
. :,;:If'YQu-nave'additiQnal.q~estiQ~S, write to:' . ..'.:,.d6nst~uction CQntractors. BQa~d . '\
, , " , . ~700 'Summer 'Sf. NE, Suite '300 " \,
".'., . ">Sal&m-6R97310~151>' .::.":...,,,..
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Phon~ ,503-37&4621 ' .
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