HomeMy WebLinkAboutPermit Building 1992-04-28GFTELE)
RESIDENTIAL
PERMIT APPLICATION
lnspections: 726'3769
Of tice: 728-3759
Locl\l loN of' PRO
ASSESSORS MAP:
POSED WORK:.
JoB NUMBE n 2?427 --225 Fitth streetfuf4< 7
Sprinsfield, Oregon 97477 TAA/
24?
TAX LOT:
SUBDIVISION
PHONE:OWNt:R
ADDRESS: - -
CllY: .. ..STATE:ZIP: -
DEMOLISH OTHER
DESCRIBE WOR
NEW _-_- REMODEL ADDITION
EXPIRES PHONEADDRESS
MECHANICAL
CONTRACTOR'S NAME
C EN ERAL:
EI-ECTRICAL
I'LIJ M BINC
CONST.
CONTRACTOR #
I OF UNITS:# OF BLDCS
- OFFICE USE _
LAND USE:
RANGE:
HEAT SOURCE
OLrAt) ntltrn
CONSTR. TYPEOCCY GROUfJ:
# OF STORIES: -
WATER HEATER: --
To request an inspection, you must call 726-3769. This ls a24haur recording. All inspections requested before 7:o0 a.m. will be
made the same working day, inspections requested after 7:00 a.m. will be made the following work day.
REOUIRED INSPECTIONS
fl Temrlorary Electriclr
Rough Mechanical - Prior to
cover.
f7l final Plumbing - When all4 plumbing worl< is comPlete.
f-71 Final Eleclricat - When allUIJ electrical work is coutplete.
Sile tnspection - To be made
af ter excavation, but P.rrior to
setting lorms.
Rough Electrical - Prior t<:
COVET
Underslab Plumbing/ Electrical /
Mechanical - Prior to cover.
Electrical Service - Must be
approved to obtain Permarlcnt
electrical power.
w Final Mechanical - When all
rnechanical work is complete.
Footing - Af ter trenches are
excavated.Fireplace - Prior to facing
materials and framing lnsp.
W Final Building - When all
required inspections have been
approved and building is
completed.Masonry - Steel location, bond
bearns, grouting.A
w
w
Framing - Prior to cover
Other
Foundation - After {orms are
erected but Prior to concrete
placernenl.Wall/Ceiling lrrsulalion - Prior to
cover.
Underground Plumbing - Prior
to filling trench.Drywall - Prior to taping
MOBILE HOME INSPECTIONS
Undertloor Plumbing/ Mechanical
- Prior to insulation or decking.Wood Stove - After installation.
Post and Beam - Prior to floor
insulation or decking.lnsert - After firePlace aPProval
and installation of unit.
Blocking and Set.Up - When all
blocking is complete.
Floor lnsulation - Prior to
decki ng.Curbcut & Approach - After
forms are erected but Prior to
placement clf concrete.
Plumbing Connections - When
home has been connected to
water and sewer.
Sanitary Sewer - Prior to filling
trenclr.Electrical Connection - When
blocking, set-up, and Plumbing
inspections have been aPProved
and the horne is connected to
the service panel.
Slorm Sewer - Prior to filling
trench.
Sidewalk & DrivewaY - Af ter
excavation is comPlete, forms
and sub-base material in Place.
Water Line - Prior to filling
trench.
[l fence - Wlren comPleted.
Slreet Trees - When all rL'quired
trees are planted.
Final - After all required
inspections are approved and
porches, skirting, decks, and
venting have been installed.E Rouglr Plumbing - Prior to
cover.
LOT: __ _ BLOCK:
FLOOD PLAIN:
ZONING CODE:
r OF BDRMS: .-.
SECONDARY HEAT:
SOUARE FOOTAGE:
tl
r
il
tlr
fl
w
w
r
Lot faces
Lot sq. ftg.
Lot coverage
TopographY
Total height
Lot Type
_- lnterior
--
Corner
-
Panhandle
-
Cul-de-sac
tbacks
P,L.HSE GAR ACC
N
.)
E
THE PROPOSED WORK IN THE
-flrsroRtcAL Dlsrnlcr, oR oN
Tl.IE HISTORICAL REGISTER? -.--
lf yes, this application musl be signed
anrl approved bY the Historical
Coor<Jinator prior to perrnit issuance
APPFOVED:
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is grantecl on the express condition tl"lat the said
construclion shall, in all rcspects, conform lo the Ordinance
adopted by the City of Springfield, including the
Development Cocle, regulating the construction and use of
buildings, and may be suspended or revoked at any time
upon violation of any provisions of saici ordinatrccs
/;3a+zewed By
Plan Check Fcc: .
Date Paid
Receipt Nuntber:,
Recei
VALUE
(A)
@a
X $/SO. FT.
Total Value
Building Permit Fee
State Surcharge
Total Fee
38,*
/-?7
40, p
BUILDING PERMIT
ITEM SO. FT.
Main
Garage
Carport
Systems Developtncnt Charge is due on all trndevcloped
properties within the City limits which are being irnproved.
GE (sDC)SYST S DEV LOPM
1-
ADDITIONAL COMMENTS
ITEM
Fix t u res
Flesidential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
[= EE
(c)
74-Zz-{2:"
7" ?5
€
ng
N0
FT.
FT.
Plumt;i
PLUMBING PERMIT
State Surcharge
Tot;rl Ch;rr1;e
FT.
Wood Stove/ lnsert/ Fireplace Unit
Dryer Vent
Mechanical Pet rnit
(D)
N0Vent Fan
lssuance
State Surcharge
Total Permit
MECHANICAL PERMIT
Fu rn;rce
Exhaust Hood By signature, I state atrd agree, that I have caref ully examined
the completed application and do hereby certi{y that all
information hereon is true and correct, and I f urthcr certif y
that any and all work pcrlormecl shall be done in accordattcc
with the Ordinanccs of the City of Springf ield, and the Laws
of thc Statc oI Orcl;ott llertaining lo the worl< rlc.';crillr-'tl
hcrein, artd tltat NO OCCUPANCY will bt-' trt;-tclc of :rtry
structure without pertrtissiot't of tlre Building Safety Division.
I further certify lhat ottly contractors and employees who
are in compliance with ORS 701.055 will be used on this
proiect.
I further agree to ensure that all required inspections are
requested at the proper time, that each address is readable
from the street, thal the permit card is located al lhe front
of the property, an(l thc approved set of plans will rernaitl
during cons\uctionon the
Signat
Date
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk --- ft
Curbcut
-=-
ft
Demolition
State Surcharge
Total Miscellaneous Permits (E)
VALIDATION:
RECEIPT NUMBER
DATE PAID
AMOUNT RECEIVED
//* r
FIECEIVED BY
-_
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, Q ancl E Combined)
Z?-.2/
/;%:e
(B)
C'TY OF OPEGO'U
225 FIFTB STRBEf,
SPKINGFTBUD, ORBGoN 97477
INSPBCIION RBQIBST. 726-3769
0FFICE: 726-3759
1. LOCATION OP INSTALI.ATION
IJGAL DESCRIPTION^^ ^1 e2'a>
JOB
Permits are non-transferable and expireif vork is not started vithin 180 daysof issuance or if vork is suspended for
180 days.
2. COMRACTOR INSTALI,ATION ONLY
Electrical Contractor
Address
ci ty- Phone
Supervisor License Ndmber
Expiration Date
Constr Contr. Number
Expiration Date
Signature of Supervising Electrician
0wners Name
Address *?
BLECTRICAL PERfiIT APPLICATION
ci ty Job Number
Nev Residential-Single or
HuIti-Family per dvelling unit.
Service fncluded:
Items Cost
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereo f
Each Manuf'd Home or
Hodular Dwelling
Service or Feeder
$ 8s.00
$ 1s.00
s 40.00
B. Services or Feeders
fnstallation, Alterations or
Relocation:
200 amps or less
201 amps to 400 amps _401 amps to 600 amps _601 amps to 1000 amps
Over 1000 amps/volts
Reconnect only
C. Temporary Services or'FeedersInstallation, Alteration or Relocation
0b
200 amps or less
201 amps to 400 amps
-0ver 401 to 600 amps _Over 600 amps or 1000 volt
strtrtNGFrI:Lo
STIBTOTAL OP ABOVB
5Z State Surcharge
TOTAL
3
A
Sum
60ve
00
00
00
00
00
00
$ so.
$ 60.
$100.
$130.
40$
s 40.00
$ ss.oo
$ 80.00
s see ilBtr a
$300
D. Branch Circuits
Nev, Alteration or Extension Per Panel
One Ci rcui t '/
Each Addi t ional
Circuit or vith Service
or Feeder Permi I Z.OIINER INSTALI,ATION
The installation is being made on
property I own vhich is not intended
for sale, Iease or rent.
Ovners ture:
DATE:
RECEIPT
ff7/"-22/a"l*/##r $ 3s.00
$ 2.oo
_€Ci ty Phon
E
5
Miscellaneous (Service/feeder
-Each installation
Pr.rmp or irrigation $
Sign/Outtine Lighting- $
Limi ted Energy/Res $
Limi ted Energy/Comm S
not included)
40.00
40. oo
20. oo
RECEIVED BY:
dP
-+z? q?^---Az. _
1
2
Permit No:
Address:
lssued Date:
R OFFICE USE ONL
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIB!LITIES
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 in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
A My general contractor is
Contractor registration number-.
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
3.B I will be my own general contractor.
lf I hire subcontractors, lwill hire only subcontractors registered with the Construc-
tion Contractors Board. lf 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 certily that the above information is correct and that I have read and understand
the tnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
f'28'ez
S n ure o Pe t cant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
3
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PiNK COPY TO APPLICANT
CITY OF SPR OREGO'V
SP. /GFIELO
DEVELOPMENTSERY'CES
PUBLICIIIIORKS
M ETN O PO LITAN WAST EWAT ER M AN AG EM EN T
Hay 31 1991
Scott Gese
2063 North 2nd Street
Sprlngfleld, Oregon 97477
Dear Hr. Gese:
Sincerelyt
Llsa Hopper
Buildlng Technlclan
cc! Dave Puent, Bulldlng Offtcial
Ih
Your request for an extension of your permits to construct an addition
io Vour resldence located at 2063 North 2nd Street, Springfleld,
o'eson, Ctty Job Numbers 900032, has been revieved and approved.
The extenslon may only be granted one time and vill expire l8o^days
fiom the date of'tt"-Sr.nting of thls extenslon (November 3, 1991)'
If you have any questlonst gr_lf I may be of any asslstance, please
feei free to phone me at 726-3790'
225 FIFTH SIPEEI
SPRINGFIELD, OR 97477
(503) 726-s7s3
i.;,. t-1.|; :t,'iir...
t,,
"'
- ':.',;. " ' l' "
qDDo 37--z /s 4 40PP4R
7z-l< caztp/eT/oN 24r€ Or ouR B<TAtaon ,400rTt om
//r4 S 6G€N SZouuee Doe rc l&cr oF Fu*roS *t/
Borc D rto< pGRrn rT /UO- Qooo32 Z-xptRe s oa) ruA?
Ano Z Ah R€ytu€rTtne /4 a -xGpTt an> oN UqiT,&RtnrT
T/-/A/{K PoJ
Scar,4.dasd
Zad 3 ^r.Z;g s/.
7 /?Et
CITY ff .]; F;E !D
,fr
225 PTYTE STREET
SPRTNGFTELD, ORBGON 97477
INSPECTTON RBOrrEsT,. 726_3769
OFPTCB: 726-3759
1 LOCATION OP INSIALI.ATION
2nd2I'lo rth
JOB DESCRIPTION
Service cha nge
Address 6il West "Q" Street
phone 747-6638
Supervisor License Nunber
Expiration Date 10/1 /92
I 4735
Constr Contr. Number 20-87C
Explration Date 10/1 /91
Slgnature of Superviislng Electrlclan
COHPI^EIE PEE SCESDI'I^E BELOV
Nev Resldential-Single orIlultl-Famlly per avetting unit.Service Included:
Itens Cost Sum
1500 sq.ft. or less S g5.OO
Each additional 500sq. ft or portion
thereof
Each Hanufrd Home or
-
$ 15'oo
Hodular Dvelting
Servlce or Feeder S 35.00
Servlces or Feeders (10 Branch Circuitslnc-luded). Installation, aiier"tion"or.Relocation:
100 amps or less
101 anps to 400 amps T-401 amps to 600 amis
-601 anps to looo arnos-Over 1000 amps/volts
Reconnect Only
Temporary Servlces or FeedersInstallatlon, Alteratlon or Relocation
201 arnps to 4oo amps
-
a 4o:ooover 4ol to.6oo amps
-
S go.oo
Over 600 amps or rboOEfEs """ ,ii aE6IE
Branch Circuits
Nev, Alteration or Extenslon per panel
EI.ACTRICAL PERTTT APPLICATTON
City Job Nunber
s 3s.00
$ 60.00
s 90.00
s130.00
$300.00
s 3s.00
A.
3
B.
c.
D.
B.
Permits are non-transferable and expireif vork ls not started ulthin 1gO daysof lssuance or if vork is. suspended for180 days.
2. COITTRACTOR INSTALINTION ONLY
Electrical Contracto.L.R. Brabham, Inc.
6u3rl
4
Ovners
Address
Scott Gese
2063 N. Znd
ci Spri ngfi e1 d phone 726'0092
DATE:
One Circult
Tvo to ten Circuits
Each AddtrI ten orportion thereofOgNER TNSTALIATION
The installation is belng made onproperty I ovn vhlch ls not lntendedfor sale, lease or rent.
Ovners Signature:
s 3s.00
s 50.00
s 15.00
BRECEIVED
Hiscellaneous (Service/feedir not lncluded)-Each lnstallatlon
lytp.9. -irrlgatton S 36.00srgn/outline Lightins- S :e.OoSignal Circult orlimlted energ.y panel_ $ 36.00
STETOTAL OP ABOVB 60. OO5Z Stdte Surcharge
TOTAL
J. UU
5
63.00
QI DI
City Springfield,
/
Rccej tlt.. RESIDqNTIAL..
" APPLICA, I/PERMIT
225 North Sth Stneet
Spr"Lngfield, 1regon 97477
Building Diuision
7 26-3? 53
SPFIINGFIELD
@ sT sfFto, cv? . q 7? 77Job Location:
Tcr Lot; llAssessore Map fl D
Subdiuision:
Ormer:
Phon,e: /26i -AO?Z'3 fl.zeAddtess
City:2<zip
DescrLbe- L'otl<:
Value
Neu
*a_72Date of App Lical;ion
6,q-r4fkora tczztTtoFAdditian
RemoCeL
r rac
General
Plurnbing
LIec c
Iil,ec Lr ca
Elec I r c 1a r')Su erv
DEI,IOLITIO!'1 OR !.iOVE) BU
Sani:at'g seuet' eapped at pnopert'g Lire
Septic tanl: p;i:ed and fi,Lled uith gra:sel
Ftnal - It4ren abcue 'itens are ecnpleted
and when Cerncli.tton ie complete o" st"1,3-
ture noued and pt'eniees cleaneC up.
llobi.Le Ilcnes
Blocking aruJ Set-up
Plwnbin;1 connections -- sareY anC uatet
Electrical Ccnnection - Bloeking' set-uc
and plwnbing conneetions tr;st be approe,l
befot:c requesting eleelrical inspeelio::
Acceseory BuilCing
Final - After pcrekes, skirting, decl<s,
etc. are completed.
Page 1 of 2
It ia the responsibility of the pemit hodet' to see
fnon the street, ard that the permtt card is Located*Buitding D,iticiot appro"-ed plan shcl.L remain on the
that aLL inspecl;ions aye nade at the ptoper time, t!"at ecch addtess is readabie
at the front of the proPertY.
Building Site at aLL times.
pRocEDURE FoR INilqECTON RgeWS?rCalU726-3769 (t,ecotd.er) state yout'cit11 desi.gna-ted job nwnber, iob aCiress, \!ee-of inspecticti
eadyforinspection,Contraetorso-,asnn,o-,tcawandphonerulnber.Requestsrecettedbefcre7:00an'sill be rrude the sone dcy, ?equests ncde after 7:00 an uiLL be nnde the ncrt aorking day.
SITE fNSPECTI2N: To be nade aftet
etcalation, but pt"ior tc set up of
forms.
yourtCitA Designated Job Nunber Is:
INSULATION/VAPOR BARRIER,TIISPEC'TION :
?o be made after aLL insul;;ticn atd
raquired oapor batrie?s a.!e in place
but before ang Lath, gApsuln bcard or
tnLL cotsering i.s applied, aru7 before
ary iwulation is cotzcealed.
m
f .':1 DRyHALL INSPECTI)N: Tc be made
I 4l ma-m-AA;ffts in ptace,
but prlor to cna Daplng.
w
UNDERSLAB PLUMBING, ELECTRICAL &
ULCX[!!!AL: To be made before ang
ffiF-li-i6oeted.
FOOTING & FOANDATICN: ?o be IruCe
after tnenches a?e e-acaoated and.
forns ate erected, but prior to
pouring ccncrete.
I,|AS0NRI: Steel Location, bond
ffilglouting or oerticcls in
accordotee Dith U,B.C, seetion
2415.
l,lOODSTOttE: Aftet' installation is
atnpleted.
-t) uNDERcRout\tD pLUMErNc. sEwER, vATER,u9
Lir.g trenchee.
lT1 upocnprcoR pLrJtErNG & MECHANTGAL:i^l "ffloor inaulation ot decking.
f-lV post AND BEAM: To be nade pnior to
W T;;t;TGrlo" of floon insulbtion or
decking.
t-Tlt ROUGH PLU\IBIIIC. ELE|TRICAL & MECH-lAt
-
until these inspections hante been
made and. approued.
FIPEPLACE: PrLot to placirq facing
materials and befote frani.ng i.nepee-
tion.
FRA\IINC: ttust be requested aftet,
approoal of rough pltnbing' electti-
cal & mec?wnical. ALL roofing
braci,ng E chinmegs, etc. tmtet be
eompleted. !1o aork ie to be con-
cealed until this inspection has
been rade anC approtted.
SIDEWALK & DRfltEllAY: For aLL eon-
;Cte paufi tifiln stt'eet right-
of-teA, to be made after aLL etea-
oating conplete & fotn wrk & aub-
base naterial in Place.
CURB & APPRCACH APRON:
oa,.-e"."iA-i;, p;l;i
concrete.
IENCE:
saa
After fonnsto pouring
hrhen conplete -- ProoiCe
or mouable sectians tl*ough
P. U. E,
w
m
FIIIAL PLUMBING
FINAL MECHANICAL
FINAL ELECTRICAL
@
ALL projeet oonditions, sua!.t as bhe i.nstallaLion of s!;reet trees, ao'nyLetion-of the
"nq"Z"L|-ii"a"eiping, Ztc., mtst be satisfted before the BUILDTNG FII\AL can be requested'
7INAL BUILDING: The lti.nal Building Inepcction ntuet be raqueated aftet' the Final Plwnbing
Electrical, and Mechanical Inspeeblons Ttauc been nade and appt'ooeJ'
*AT,L MANHCLES AND CLEANOUTS TIUST RE ACCESSIBLfr, AD,II]STIIENT TO BE I,|APE 'i.T NO C1ST TO EI?Y
Date:
I)1re
7L/ 77
t--.1
TotaL
SOLAR ACCESS REQ.-
Cro
L-co c
Bedrooma
I IIAW CAREFULLy SXAI|INDD the cornpleted appltcation fon permit, and dolereby cet,tifll that aLL infornation heteon ie trwe and cbtnect, cnd. f
J\t'ther cet,tify that any ar.d aLL uork perforned slnll be done ini accor-
dance l,rLth the 0ydinances of the City of Sprtngfield, and the Laa of theState of 1regcn pet,taining to the uork Ceseribed herein, cnd. tlnt N0 OCCU-
PANCY DilL be rmde of any structure aithout penniasion of the Bui,l,ding N-uision. I furthen certify that only contracTors and anplcyees uho ara in
eonpl,'ianee uitlt )RS 701,055 uiLL be used on thie projeet
["ot Faces -Energg Souncee T11oe
Setlncks Ileat
llotise Cat,aoe Aaeess l,lateP lteatet,16rtti-Range
ljas t Fireplace
Sor.i.t.lt htoodsto"^e
% cf lot Ccuerage_
I of Stories
Total Height
I,OT TYPE
_ fntenicr
_ Corner
_ Panhandle
Cul-dt:-saeTopography
Lot Sq. Ftg
lle;t t
-- Fees --
TTEM X Value Building Volue & Permit
Tlt.i-:; pet,rnit is granted on the etcpress condition tlnt the sciid-constntetion
s)n17., itt all rbspeets, confonn to the Ondirnnce adopted by the Ctty of
Slrt'irt,Jfield, i.ncluding the Zoning Crdinanee, regulating the ccnsttucticn
and use o!'bu'ildtngs, and may be suspended or neookeC at cnA time upon oic-
luLton oJ' any l)t,cuisi.ons of said Ordinances.
?OTAL VALUE
DCS.D.C. 1.5 x *
Building Pet"wLt
State L)ate Paid:
Receipt #:Total Clarges Siqned:
I7'EM NO.T'L'E CHARTiL'Plumbing PerrnitFi-rtures
Residential (1 bath)No perton slnll. construct, inetall, alter ot clnnge anA nel cr eristing
plwnb'tng on dtainage systen in uhole or in patt, unless such person is thelegal possessor of a oalid phtnbet,'s License, eeeept tlnt a pe?eon nny do
plunbing uork to property uhich ie ouned, Leased or opetated by the appli-
cant.
Seuer -zo.*
Plunbing Pern:it
State St*charqe 2-aA
*
Electricol Permit
h4rcve State La requires tlnt the electrical uonk be ilone by an Electnieal
Conbracton, the eleetrical portion of this pernit shall not be oaliC untilthe Label luts been signed by the Electttcal Contractot,.
Iotal
NO
NailErtend Circuits
Set'uice
2Z-:r>
NC FqLI CllAltr;l;
I
Vcodstoue
*
*
Mechq n ic o I Pe rm it
Eshanst HooC
Vent F@l
Penntt fssuanae
Mechanical Pernrtt
-- EIlCROAC',iluEilr --
Sean ity Deposit
Storage
Maintenance
Permit
Curbeut
Sida,talk
Fence
Electrical Ia.bel
f'lobile Hotne
/5'7.a7
*
Dal:e
JOB NO.
/'??-:-
udxe
Z
7.s,o =2 <->
-/,-aB7
S2-Sa
State Sutcharee
Total Clan aes
'!'(.t'fAt At!0uNT I)UE: ^
/?70
Permit No:
Address
lssued te
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILTTIES
Note: Oregon Law, ORS 701.055(4), requires residential building permit applicantsyl.o ale 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), neednot 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 2F..
1:-Ft I own, reside in, or will reside in the completed structure.
2. A. l--l 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. Ef I will be my own general contractor.
lf I hire subcontractors, I ryill hire only subcontractors reoistered with theConstruction Contractors Board. ltl cha-noe mv mirid ;riti'Edh-ir6? oeiiieii-icontractor, Iwill contract with a contrattor'who is reoisleieO-wi[n1nGConstruction Contractors .Boqrd and I wi I I immeo ia1el11-nolIiilne' bitiC6issuing this buitding permit of the name or tne contiiitcii.
I hereby certify that the above information is correct and that I have read and understandthe lnlormation Notice to Property Owners about Construction Responsibilities on thereYerse side of this form.
#l^71 /@gnapplicantDate
CONSTRUCTION E,ONTRACTORS BOARD
o244J 10l24tp
WHITE COPY TO ISSUING AGENCY PERMIT FILEPIffi COPY TO APPLICANTi ,t.. .-r"Lr-i1i. l_i_ @s :
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