HomeMy WebLinkAboutPermit Plumbing 1992-6-30
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-.. SPAIFIELD
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: ~~~Lo~ (t~oJjilif\ "bti:\flQ J 'Kci-
Assessors Map II: \\()~ \c::r~\ \ J Tax Lot II: . ~Pt()~
Owner: ffi l\';Lu9., .t\[\\i D~) . .
Address: ~31 n.~ ~ On ~ ~rtrhone H:i4-1 ~lF{)~
City, FL (\ St,t,,' (oPQ~ z;" o.l:1JJ
Backflow Penmi is $15.00 + $0.75 State Surcharge
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Contractor:
Address:
Dhone H:
City:
State:
Zip:
Construction Contractors Registration H:
Expires:
By signing this permitlapplication, 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 applicationlpermit is
correct,
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Uate
FOR OFFICE USE
Date of Application: W o,2{) .q A. Job II: q8~
Receipt II: ~ ~Lol 0 Issued By: (j I [() )
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Total Amount Collected:
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Permit No: ~ Q~ Q. 11
Address:a.)ln~ ~ qdm 0\ ~X
Issued b~ tffi ~ _ DWJ.fl(1)q~__
~OR 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 ~n tJj applicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
1. ';fLJ; I own, reside in, or will reside in the completed structure.
2. I undersland that I must regisler as a conslruetion contraclor if Ihe structure is sold
{ or offered for sale before or upon completion.
3. A.I
I My general contraclor i~
Contractor registration number
I will instruct my general contractor that all subcontractors who work on Ihe struc-
ture must be registered with the Construction Contraclors Board.
OR '
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I' I hire subcontractors, I will hire only subcontractors registered wilh the Conslruc-
lion Conlraclors 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 nOlify the office issuing this building permit of Ihe name of
the conlractor.
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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LSignat -e of Permit Applicant
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Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
INFORtlTION NOTICE TO PROPERTY O.ERS
ABOUT CONSTRUCTION RESPONSIBILITIES
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NOliE: \ ; This Information Notice to Property Owners About Construction Responsibilities
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was developed by the Constr\'!ction Contractors Board in accordance with ORS 701.055(5),
,p~ssed by Ihe 1989 Oregon legislature.
:' \f yo~ ~re '~cting as your ~wn contractor to construct a new home or make a substantial improvement to an
existing structure, you can prevent many problems by being aware of the fOllowing responsibilities and areas
of concern.
EMPLOYER RESPONSIBiliTIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisling
in the construction or improvemenl of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will be "employees". f!.s the employer, you must comply with the fOllowing:
Oregon's Withholding Tax law: As an employer, you must withhold income taxes from employee wages at
the lime employees are paid. You will be liable for the tax payments even if you don't actually withhold the
tax from your employees. For more information, call the Oregon Department of Revenue at 378-3390.
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For more informalion, call the Oregon Employment Division DHR
at 378-3224.
'Norkers' Compensalion Insurance: As an employer, you are-subject to the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers'
compensation insurance, you may be subject to penalties and will be liable for all claim costs if one of your
employees is injured on the job. For more information, call Ihe Workers' Compensation Division DIF at 373-7434.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages.
You will be liable for the tax payment even if you didn't actually withhold the tax. For more information, call
the Internal Revenue Service al 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
~ode Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requiremenls Ihal may be brought 10 your allention through inspeelions.
Liability and Property Damage Insurance: Contacl your insurance agenl to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure you have sufficient lime to supervise your employees.
Experlise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
If you have additional questions, write to:
Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
0244J 10/24/89