HomeMy WebLinkAboutPermit Plumbing 1991-8-16
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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: c9r;_'i5F~ ~ fho~);
As.sessors Map I.: \l~~. Tax Lot n: 0f1{ Om
Owner: mf\ ~ORjV
Address: C9'J<6~ . (l/)J\f( Q~ ~hone II:
City: ~J-d State: ~
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Zip: qli77
Address:
Phone II:
City:
state:
Zip:
Coristruction Contractors Registr~tion II:
Expires:
Yi&h/
Date ( ,
FOR OFFICE USE
Date of ^PPlicatio0n ., '.lo) \C{ClI "Job I: q rCHb J
Receipt II: c9 /ci..~Zj Issued By: (S7f lj)~) .
Total ^mount Collected: \ "S .i\~ .' ,- \ .~ , .
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Permit No: C, r91 (f) 7 . .
. Address:rCfl~-~ ('fr/N{{Z~ ..
Issued by:(f:1{)) (\~:te: -75, l/'i ,Cj)
5T ATEM ENT:
. . INFORMATION NOTICE TO'PROPERTY OWNERS
. ABOUT CONSTRUCTIONRESPONSI BIUTI ES
. Note: Oregon Law, ORS 701.055(4), requires residential building permit applicants
who are not registered with the Construction Contractors Board to.sign the
.following statement before the building permit can be issued. 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 i7t~e applicable blanks, and initial box 1 and either box 2A or2B:
1 \~ () . I own, reside in, ~r will reside in the completed structure.
"\
2.A:'1 My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board. .
OR /
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I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the
Construction Contractors Board. If I change my mind and 00 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 sJ9L.o.f this form. . . I
. \ 7),u ~ fJ 1t!!/f-UI. I
&i'gnatureof Permit Appiicanf - .
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57'/&,h/
Date I
C NSTRUCTION CONTRACTORS'SOARD ' .
0244J 10/24/89' ' .
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" ~-tt COpy TO ISSUING AGENCY PERMIT FILE
~TOAPPLICANT . ~, .~