HomeMy WebLinkAboutPermit Plumbing 1990-4-3
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SPlFIELD
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 Locat ion: 41lp L(x...h a II ~ (/\ ]I/..e,
Phone II:
7z6 -7303
Zip: 97L/ 77
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Assessors Map II:
Owner: r:: VC,U/I It..- (\f,,;/ A /1/1 cr
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Address: Lf/~ L.Oc.h()./lbl Mv
City: ~yjV23f7 -e I,J State: 07L-
Tax Lot II:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: {hAJ1J\.L.;V
Address: Phone II:
City:
State:
Zip:
Expires:
Construction Contractors Registration II:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application(permit is
correct.
S,g"t""~~"~ ~~
Date
Y;//CJ
FOR OFFICE USE
Date of Application: L-j-3-1D
Receipt II: 1(P 11 '1 rz, Issued
Total Amount collected:$l1e:::.. --1'5
Job II:
By:.il,III./A'
1003Cjg'
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Permit No: q 0030 ~
Address: 411~ Lochn..v'..e,Vl {lVv
Issued by: (1 MAid ~ Date: 1-\ -3 - 10
STATEMENT: .
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
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Note: Oregon Law, OAS 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 OAS 701.010(7), need
not submit this statement. This statement will be filed with the permit.
Fill in the applicable blanks, and initial box 1 and either box 2A or 2B:
1. L...:::J
.....
I own, reside in, or will reside in the' completed structure.
2. A. L-J' 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
B. L-J 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 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.
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Sigrfatu're oPPe'rinit ~~fi7 Date /;- t9
CONSTRUCTION CONTRACTORS BOARD
0244J 10/24/89,
WHITE COPY TO ISSUING AGENCY PERMIT FilE
PINK COPY TO APPLICANT
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