HomeMy WebLinkAboutPermit Plumbing 1991-10-4
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BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759.
INSPE~TION LINE: 726-3769
Job Location: "'\^,~4 &\J\..J"..2bL!LQ.'j::,
Assessors Map II: ,~~ \ CJ_. Tax~H: 6, \oLf')
Owner:, f\\()(~f\ S~c1~
Address-: /~--114 ~\ ') l ~,..-S\- _ U,hone H: 14-1-ln<6
City: .sJ)---f-'\ ro... ~tate: l \Jf ) Zip:
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Backflow Permit is ${O15.00 J: $.o~tao" ~_. harge
Contractor: :x J.....}! \ ~Z/
Address:
Phone II'
City:
State:
Zip:
Construction Contractors Registration H:
Expires:
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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). Iralso st~~h~t^a12 ~ormati9n:on this application/permit is
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FOR OFFICE USE
0." of APPli"'i",~D . 4. q / ~ Job I, . QJf141u
Receipt fl:d~\17 Issued By: /~~
Total Amount Collected: 1 M.11 ')
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Permit No: Y! ( J4- Lp.l..o C' +-
Address: ~ 14 ----'1; ') lk u I
Issued b/ '}} L("fAJ Date:\:::,/().4Q (
FOR OFFICE USE ONLY
., STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS .
'ABOUT CONSTRUCTION RESPONSIBILITIES
.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 in the applicable blanks, and initial box 1 and either box 2A or 2B:
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1.V
2. 'A. L-J
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I own, reside in, or will reside in the completed structure.
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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B.
I will be my own general contractor.
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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 side of this form.
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Signatlife of Permit AppliC<Eiht
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Date
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CONSTRUCTION CONTRACTORS BOARD
0244J 1/90
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I 'I' +- WAITE COPY TO ISSUING AGENCY PERMIT FILE
lv \.U. L E1NK COPY TO APPLICANT
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