HomeMy WebLinkAboutPermit Plumbing 1990-05-18BACKFLO\,I PREVENTION DEVICE qEryIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPFIIIIGFIELE,
Off i ce:
INSPECTION LINE:
726-3759
726-3769
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225 Flfth Street
Springfield, 0regon 97 477
Job Location:(t 0,
Assessors MaP #:
0wner:
Address:
City:State:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
Address:
Tax Lot #: Aa
Phone #:
Zi p:
Phone #:
City:State:Zi p:
Construction Contractors Reg'istration #:Ex pires:
By s'igning th'is perm'it/application, I agrgg to ca'll for an_'ins-pection once the
bickfiow [revention dev'ic'e has been 'instal led and is visible forinspection
(726-3769'). I al so state that al I informat'ion on this appl ication/permit is
correct.
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Date of App'l i cat i o n
Receipt #:t (
FOR OFFICE USE
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Total Amount Collected:
Issued By:
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Permit No:
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Address:
lssued Date:
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Fill in the applicable blanks, and initial box 1 and either box 2A or 2Fi:
I own, reside in, or wirr reside in the compreted structure
My general contractor is
Contractor registration number
l.will instruct my general contractor that all subcontractors who work onthe structure must be registered with the Constrr.tion Contractor" Ao"iO.
OR
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Note: Oregon Law, ORS.701-055(4), requires residential buitding permit applicantsyLo ale not registered with the Construction Contractors bbard to'iign tnefollowing statement before the building permit can be ir.r"oi. ri".lrl#nichitectand EnginggJ.appticants, exempt frori iegistration Lno"'. oRS%1.oiddi, n"eonot submit this statement. This statemeit wir be tiiJo witn in" pJrriil
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1
2. A.
I will be my own general contractor.
lf I hire subcontra.ctors, t will hire-only subcontractors registered with theConstruction Contractdrs BoaiO. tt,qo n ii d c t-; ; r il,ir i c o n t r a c t _w i i r " i skffi,"SJfl i" ?:s ij:?.{ bjffi tl irtConstructibn contraCiois-aoa;iJA;J'i'riiti"ihiii6tii"t"ry notify the officeissuing this building permit ot tne nime i;i ih;'ddniiactor.
l.herely certify that the above information is correct and that I have read and understandthe lnformation N,oti.ce to Property owners auoul-construction nlsponsibilities on thereverse side of this lorm.
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ure m App t Date
COPY TO ISSUING AGENCY PER MIT FILE
CONSTRUCTION @NTRACTORS BOARD
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COPY TO APPLICANT
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