HomeMy WebLinkAboutPermit Building 1993-05-27SPrl ELE'
RESIDENTIAL
PEBMIT APPLICATION
lnspections: 726-3709
Of fice: 726-3759
JoB NUMBE ^ Qzal+q
225 Fifth Street
Springfield, Oregon 97 477
&
LOCATION C)F PFIOPOSED WORK:<39 N .lz4
ASSESSORS; MAP:
-
r-) o?i r ?1,TAX LOT:o Ll 80c
LOT: ---BLOCK:SUBDIVISION
PHONE:
ztP'.AASTATE:
OWNER:
ADDRESS: _
CITY:
NEW
--
REMODEL ADDITION DEMOLISH OTHER
oescAtae woRK:
ELECTRICAL: -=--
EXPI RES PHONEADDRESS
-Owx-',o
rr
PLUMBING
MECI-IANICAL:
CONTRACTOR'S NAME
COr\lST.
CONTRACTOR #
G EN ERAL:
RANGE:
# OF BDRMS
_ OFFICE USE .-
ZONING CODE:
FLOOD PLAIN
OCCY GROI)P: _ _
SECONDARY HEAT
SOUARE FOOTAGE:
OUAD ARE/r:
, OF BLDGS
CONSTR. TYPE:
HEAT SOURCE:
LAND USE:
# OF UNITS
' OF STORIES:
--WATF-R HEATER:
To request an inspection, you must call 726-3769. This is a 24 hour iecording. Ail inspections requested before 7:00 a.m. will be
made the same working day, lnspections requested after 7:00 a.m. will be made the following work day.
REOUIRED INSPECTIONS
Rough Mechanical - Prior to
cover.
Final Plumbing - When all
plumbing worl< is complete.
Site lrrspeclion - To be made
after r-,xcavation, but prior to
setting forms.
Under slab Plumbing / Electrical/
Mechanical - Prior to cover.
Footirrg - After trenches are
excavated.
Masonry - Steel localion, bond
beam:;, qrouting.
Founclation - After forms are
erected but prior to concrete
placernent.
Underground Plumbing - Prior
to filling trench.
Underf loor Plumbing/ Mechanical
- Prior to insulation or decking.
Posl and Beam - Prior to floor
insulation or decking.
Floor lnsulalion - Prlor to
decki ng.
SanitarY Sewer - Prior to filling
trenclt.
Storm Sewer - Prior to filllng
trench.
Waler Line - Prior to filling
t ren cll.
Rough Electrical - Prior to
cover.
Electrical Service - Must be
approved to obtain permanent
electrical power.
Fireplace - Prior to {aclng
materials and framing Insp.
Framing - Prior to cover,
Wall/Ceiling lnsulalion - Prior to
cover.
Wood Stove - After installation
lnsert - After firePlace aPProval
and installation of unit.
Curbcut & Approach - After
{orms are erected but Prior to
placement of concrete.
Sidewalk & DrivewaY - After
cxcavation is complete, forms
and sub-base material in place.
Fence - VJhen completed
Street Trees - Wherr all required
trees are planted.
Final Electrical - When all
e!ectrical work is cornplete.
Final Mechanical - When all
mechanical work is complete.
Final Building - When all
required inspections have been
approved and building is
completed.
Other
MOBILE HOME INSPE TIONS
Blocking and Set-Up - When all
blocking is complete.
Plumbing Connections - When
home has been connected to
water and sewer.
Electrical Connection - When
blocking, sei-up, and Plumbing
inspections lrave been approved
and the lroore is connected to
the service panel.
Final - After all required
inspections are approved and
porches, skirting, decks, and
venting have been installed.Rough Plumbing - Prior to
cover,
Q 1.*-l"l
1q1 -qffi4
E
Er
tl
tf
r
tl
E
n
E
E
E
tl
tl
fl
E
E
fl
E
tl
[-l Temporary Electricll
ff
[--l Drywall - Prior to taPing.
t_l
I
1
Lot faces
Lot sq. (tg.
Lot coverage
TopographY
Total height
Lot Type
-
lnterior
-
Corner
-
Panhandle
-
Cul-de-sac
Setbacks IS THE PROPOSED WORK IN THE
HISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER? =-
lf yes, this application must be signed
and approved bY the Historical
Coordinator prior to permit issuance'
APPROVED
PL.HSE GAR ACC
N
S
E
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition tlrat the said
construction shall, in all respects, con(orm to the Ordinance
adopted by the City ol Springfield, including the
Development Code, regtrlating the construction and use of
buildings, and may be suspended or revoked at any time
upon violation of any provisions of said ordinances.
DatePlans Reviewed By
Plan Check Fee:
Date Paid
Fleceipt Number:-
Fleceived By:
VALUE
.-7 S
(A)
I
X $/SO. FT,
oo
-_TSJt'
Total Value
Building Permit Fee
State Surcharge
Total Fee
<ood1
BUTLDING PERMIT
ITEM SQ. FT,
Main
Garage
Carport
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved.SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
ADDITIONAL COMMENTS
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
N0
FEE
FT.
FT.
F-r.
(c)
PLUMBING PERMIT
Plumbing Permit
State Surcharge
Total Charge
Wood Stove/ lnsert/ Fi replace Unit
Dryer Vent
(D)
NoVent Fan
Mechanical Permit
lssuance
State Surcharge
Total Permit
MECHANICAL PERMIT
Fu rnace
Exhaust Hood By signature, I state and agree, that I have caref ully examined
the completed zrpplication and do hereby certify that all
information hereon is true and correct, and I f urther certify
that any and all work performed shall be done in accordance
with the Ordinances of the City of Springf ield, and the Laws
of the State of Oregon pertaining to tl)e work describcd
herein, and that NO OCCUPANCY will be mi.rde of any
structure without permission of the Building Safety Division.
I f urther certify that only contractors and ctnployees who
are in compliance with ORS 701.055 will be used on this
project.
I f urther agree to ensure that all required inspectio\s are
requested at the proper time, that each address is readable
from the street, that the permit card is located at the f ront
of the property, and the approved set of plans will remain
on the site at all times during construction.
)
S I v
Signatu
Date
MTSCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk
-
ft
Curbcut
-
ft
Demolition
State Surcharge
Total Miscellaneous Permits (E)
_y)- E bEg
3l>tLc,z
o
CIA
DATE PAID
VALIDATION:
RECEIPT NUMBER
-
AMOUNT RECEIVED -
RECEIVED BY
-
TOTAL AMOUNT DUE (excluding electrical)
(A, B, q D, and E Combined)
I<:)<i
Permit No:qao )+q
Address:63? /0 , 33 nd-
lssued by OB
3l>-tlq,,
Slr. lez
1
2
R 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 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 numbe
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
3.8 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 certify that the above information is correct and that ! have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
3
ign re rm pp cant
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
Date
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
Date:
4
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This lnformation Notice toProperty Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1989 Oregon Legislature.
lf you hre'acting as your own contractor to construct a new home or make a substantiat iriiptdveihtinito an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern. rr
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registere_d with the Construction Contractors Bgard to do labo-r in cor.rstructing or assisting
in the constrilction or improvement of a iesidential $tlucture,'you.ryill, in most.ifi'strirlces,te''iuleO to be an
"employer" and th'e people you hire will be "employees". As the enii:ioyer, you must'comply with the following:
Oregon's Withholding Tax Law: As an emptraygr, you must withholb incomeJaxes from.employee wages at
the time ernployees are paid. You will be liable for the tax ppyments even if. you dgn'! aCtually withhold the
tax from your employees. For more information, call the Oregon Department of Revenug.,at 378-3390.
Unemployment lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For.more information, call the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation lnsurance: As an employe( you ar:e subfect to the Oregdn Workers'Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you may be subject to penalties and will b'e liable for all claim costs if one of your
employees is injured on the job. For more information, callthe Workers'Compensation Sivision DIF at 973-7434.
U.S. lnternal Revenue Service. As an empl oyer,yo u must withhold federal i ncoqe taxlrom employees' wages.
You will be I even i(you didn't actually withhold the tax. For more information, call
the lnternal Revenu at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Compliance: As the perrpit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be brouglrt to your attention through inspections.
,.
Liability and Property Damage lnSurance: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint oversprdfi'water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure:you have sufficient time to supervise your employees
Expertise: 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 notity building officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to:Construc.tion Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310{151
Phone 503-978-4621
0244J 10t24t89
I IAL
o"l? qq?^JI.I OF PROPOSED WORK:LOCATIO l? OL1tz,-
ASSESSORIi MAP: ---
JOB NUMBER
SUBDIVISION
TAX LOI
LOT:BLOCK:
225 Fifth Street
Springfield, Oregon 97477
PERMIT APPLICATION
l,'speCt' 1ns: 726'3769
Office: 726'3759
PHONE
Q-l +2"tORzlP
noL
STATE:
1q1 -q Re+OWNER
ADDRESS:
CITY:
NEW
---
REMODEL ADDITION DEMOLISH OTHER
\
DESCRIBE WORK:
EXPIRES PHONEADDRESS
"lt q lq 1n
& q1w)l
ELECTRICAL:
CONTRACTOR'S NAME
GEN ERAL:
PLUMBING:
MECHANICAL
CONST.
CONTBACTOR #
RANGE:
IT OF BDRMS:
- OFFICE USE _
FLOOD PLAIN:
ZONING CODE
SECONDARY HEAT:
SOUARE FOOTAGE:
OUAD AREA:
, OF BLDGS:
CONSTR. TYPE:
HEAT SOURCE:
LAND USE:
'4 OF UNITS
OCCY GROUP:
-.=.-=-----, OF STORIES: _--
To request .in inspection, you must call 726-3769. This is a24hour recording. All inspections requested before 7:00 a.m. will be
mactc the same working clay, inspections requested after 7:00 a.m. will be made the following work day.
REQUIRED INSPECTIONS
Temporary Electric Rough Mechanical - Prior to
cover.
al Plumbing - When all
plumbing worl< is complete.
Site lnspection - To be made
af ter excavation, but Prior to
setting forms.
[-TRough Electrical - Prior to
tJ Covef.
inal Electrical - When all
electrical work is complete.
Understab Plumbing / Electrical /
Mechanical - Prior to cover.
Electrical Service - Must be
approved to obtain Permanent
electrical power.
nal Mechanical - When all
mechanical work is complete.
Footing - After trenches are
exc avated.Fireplace - Prior to facing
materials and framing lnsP.
Final Building - When all
required inspections have been
approved and building is
completed.Masonry - Steel location, bond
beams, grouting.Framing - Prior to cover ?,
Foundation - After forms are
erecled but Prior to concrete
placement.
Wall/Ceiling lnsulation - Prior to
cover,
Underground Plumbing - Prior
to f iiling trench.Drywall - Prior to taPing.
MOBILE HOME INSPE TIONS
Underlloor Plumbing / Mechanical
- Prror to insulation or decking.[--l Wood Stove - After installation
Posl 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 tnsulation - Prior to
decki ng.Curbcut & Approach - After
forms are erected but Prior to
placement of concrete.
Plumbing Connections - When
home has been connected to
water and sewer.
Sanitary Sewer - Prior to filling
trench.Electrical Connection - When
blocking, set-up, and Plumbing
inspections have been aPProved
and the home is connected to
the service Panel.
Slorm Sewer - Prior to filling
trench.
Sidewalk & DrivewaY - After
excavation is comPlete, forms
and sub-base material in Place.
Water Line - Prior to filling
trench.l--l Fence - When comPleted.
Final - After all required
inspections are aPProved and
porches, skirting, decks, and
venting have been installed.Slreel Trees - When all required
trees are planted.Rough Plumbing - Prior to
cover.
!9$
WATER HEATEFI:
E
r
E
tl
E
fl
llorher
E
E
r
il r
P.L.HSE GAR ACC
N
S
E
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total height
Lot Type
-
lnterior
-
Corner
-
Panhandle
-
Cul-de-sac
Se k IS THE PFIOPOSED WORK IN THE
HISTORICAL DISTRICT, OR ON
THE HISTOBICAL REGISTER?
-
lf yes, this application must be signed
and approved by the lJistorical
Coordinator prior to permit issuance.
APPROVED
BUILDING PERMIT
ITEM SO. FT. X $/SO. FT.VALUE
Main
Garage
Carport
Total Value
Building Permit Fee
State Surcharge
Total Fee (A)
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMTT
This permit is granted on the express condition that the said
construction shall, in all respects, conform to the Ordinance
adopted by the City of Springfield, incltrding the
Development Cocle, regulatirlg the construction and use of
buildings, anc1 may be suspended or revoked at any time
upon violation of any provisions of said ordinarrces.
Plan Check Fee
Date Paid:
Fleceipt Number
Received By:
Plans Reviewed BY Date
SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved.
PLUMBING PERMIT
ITEM
Fixtures
Flesidential Bath(s)
Sanitary Sewer
Water
FEE
N0
FT.
FT.
FT-Storm Sewer
Mobile Home
l.v\r.,^,
Plumbing Permit
State Surcharge
Total Charge
r6 CC,
'15
(c)lqr<
ADDITIONAL COMMENTS
,A
VJL- v\z;Jr\L&
MECHANICAL PERMIT
Fu rn ace
Exhaust Hood
Vent Fan N0
Wood Stovel lnsert/ Fireplace Unit
Dryer Vent
)t t..,.r, -l5,oe
Mechanical Permit
lssuance
State Su rcharge
Total Permit
Ic cc
1S
(D)AS.?S-
By signature, I state and agree, that I have caref ully examined
the completed application and do hereby certrfy that all
information hereon is true and correct, and I f urther certif y
that any and all work performed shall be done in accordance
with the Ordinances of the City of Springf ield, and the Laws
of the State of Oregon pertaining to the work dcscribed
herein, and that NO OCCUPANCY will be merde of any
structure without pcrmission of thc Building Safety Division'
I f urther certify lhat only contractors and r-'trtployer.'s who
are in compliance with ORS 701.055 will be used on this
project.
I f urther agree to ensure that all required inspcctionP are
requested at the proper time, that each address is readable
from the street, that the permit card is located ;rt the front
of the property, and the approved set of plans will rentain
on the site at all times durin
Signatu re
Date la:,(qq
con ru$ion
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk
-
ft
Curbcut
-
ft
Demolition
State Surcharge
Total Miscellaneous Permits (E)
VALIDATION
RECEIPT N
DATE PAID
UMBER
S -)
qAMOUNT RECEIVED -
RECEIVED BY
-
-
TOTAL AMOUNT DUE (excluding electrical)
(A, B, C, D, and E Combined)
sEta(L
70'*oJ* | t-.., tr
I"+ ?+' l'','-t'i"
l3{1aut l5.q(,
'91 OL,(,
"' G,AJ tttv"k
r."l r r
( rr.i tie)
I
.,S
?.P.t l:,r-
F( r(b{aoo'i':lrl (f'
ly
2/
?,y'l)4Q,.t21, ':'-;l' I
t_,)r. "f ,,- \-lf d e I
4^- t:,'?)/)
I
Permit No
Address:
Q3o 149
53 ? /0 374/-
lssued by
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 in the licable blanks, and initial boxes 1 and 2, and either box 3A or 38:
CB fuJe-\
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
or upon completion.
i%!ra,rl:- ldl qJUJ-fl"* D,o, "r,
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK @PY TO APPLICANT
1
2 sold
3.A n ior4#7Contractor registration numbe
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, I will 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 certify that the above information is correct and that I have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
5l*.lqj
ure o rm can Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
Date:
NOTE: This lnformation Notice bProperty Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701055(5),
passed by the 1989 Oregon Legislature.
INFORiIATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
lf yoti arE dcting as your own eontractor to construct a new home or make a substantial i.r1pmil6frpnt to an
existing structure, you can preveot.many problems by being aware of the following responsibitities and areas
of concern
EMPLOYER RESPONSIBILITIES: '
lf you hire persons not registered with the Construction.Contractors Board to do labor in constructing or assisting
in the construciion or improvement of a' residential structure, you'will, in rflost instances, be'ruled to be an
"employer" and the people yglr fr.ire will be "empfoyees". As the emplbyer, you'must.comiily with the following:
Oregon's Withholding Tax Law: As an emp,loyer, you must withhold income taxes from employee wages at
the time ernployees are paid. You will be liab.le for the,tax payments even if you don't actually withhold the
tax from your employees. For more information, call the Oregon Departrnent of Reyenue'at 378-3390.
Unemployment lryqe1gq Tax, As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all ernployees. For more information, call the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation lnsurance: As an employer, you are subject to the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation,insurancerlou rnay be-subject to penalties and will be liablef6r dl claim costs if one of your
employees is injured on the job. For more information, call the Workers' .Compensation Division DIF at 373-7434.
U.S. lnternal Bevenue SeIvice: As an emplgyer, you must withhold federal income tax from employees'wages.
ev6?i-if ycir.i-didn't actually withhold the tax. For more information, callYou will be tiable for the tax payme4t
the lnternal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCEBN
Code Comptiance: As the permit hotder for this project, you'are responsible for resolving any failure to meet
code requirements that may be brought to your attention throuEh inspections.
Liability and Property Dama$b lnSuiancb: Odntact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray,:wdtdr:damage from pipe punc-
tures, fire, or work that must be re-done.
fjl'i6' .'. il* .; rr,'j..'i 'J.,.r ,.i, I ;; {', 4t.-" ... , l . i , i.i'l:.' i. 'i j
Time.to Supervise Employees; Make sure you have sufficienl time to supeMse.your ernfloyees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections. : ;,
lf you have additional questions, write to: Construction Contractors Board
7O0 Summer St. {E, Suite 300
Salem, OH 9731G0151 . :.r(.
Phone 50$Y8-4621
0244J fit24189
CITY OF OREGON
SP,i',JGFIELO
225 FTVTE STRBET
SPRTNGTIELD, ORBGON 97477
INSPECTION REQUEST: 726-1169
0PPICB: 726-3759
ll ts are non-trans ferab
1 ls not started vithin
issuance or if vork ls sus
180 days.
2. CONTRACTOR INSTALI,ATION ONLY
ectrical Contractor
Add
Ci ty
Supervisor Li r
Expiration Dat
ET,]ECTRICAL PBRXIT APPLICATION
*S9--**eilr Job Number
3. COHPIATE PBE SCEEDULB BELOIT
A Nev Residential-Single or
Multi-FamilY Per dvelling unit'
Service Included:Items Cost
1000 sq.ft. or less
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home or
Hodular Dvelling
Service or Feeder
$ 8s.00
$ 1s.00
$ 40.00
c
E.
ST'BTOTAL OT ABOVB
5Z State Surcharge
TOTAL
Services or Feeders
InstaIIation, Alterations
or Relocation:
200 amps or less
-L201 amps to 400 amPs I
401 amps to 600 amPs
-
601 amps to 1000 amPs-
0ver 1000 amPs/volts
-
Reconnect OnIY
5().oc
TemDorarY Services or Feeders
in"i"ff"iion, Alteration or Relocation
200 amps or less $ 4q'9q
,oi ;b" to 4oo amps -- t ::'99o;;r +br to 6oo am-Ps - $ Bo'oo
0ver 600 "*p" or-ibOO-'o'tt" see "B" a5ove
Branch Circuits
Nev, Alteration or Extension Per Panel
one circuit $ 35'oo
Each Additional
:l';::1":'r:il!,'""8 g 2.oo E!'o
Miscellaneous (Service/feeder not included)
-Each installation
PumD or irrigation
-
Sisn/OutIine Lighting-
l,iili ted EnergY/Res
-
Limited BnergY/Comm
L,og-llulqz
and expire
L80 days
pended for
1 OF
Sum
B
$ s0.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
.00
.00
.00
.00d
:,4"
constr con Number
Expira Date
ture of Supervising Electrici
0vners Nr
Add
cit Phone
Ovners Signature:
DATB:
The installation is being made on
pioperty I ovn vhich is not intended
ior-saler, lease or rent'
D
$
$
$
$
40
40
20
36
5
I
RECEIVBD
I
Permit No:
Address:
lssued Date
OR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONS!BILITIES
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.
licable blanks, and initial boxes 1 and 2, and either box 3A or 38:Fiil
1.
2.
n
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.
Contractor registration numbe
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
3.8 I will be my own gene+al contractor.
lf I hire subcontractors, I will 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 certify that the above information is correct and that ! have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
7*6 -?3
ig a of cant Date
CONSTRUCTION CONTHACTORS BOARD
0244J 8191
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
OR
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
lf you are acting as your owh contractor to construcl a new home or make a substantial imprcrement to an
existing structure, you can prevent filany problems by being aware of the following responsibilities and areas
of concern
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in'tne.onit*.tion or iriprovement oi''A residehtial structdie,'yotl will, in most instances, be ruled to be an
"employer" and the people you hire will be "qmployees". As th,e e.mploye:r, you must comply wjlh the following:
Oregon's Withholding Tax Lqw: As an e{np1ayer, you must withhold income taxes from employee wages at
the time 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 lnsurance Tax: As an employer, you are required to pay a tax foi unemployment'irisurance
purposes on the wages of all emplgyees. For more information, call the Orggon Employment Division DHR
at 378-3224.
Workers' Compensation lnsurance: As an employer, you are subject to the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you may be subjeet to penalties and will be lidble for all claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF al$73-7434.
U.S. lnternal Bevenue Service: As an employgr, yog m.upt withhold federal income tax from employees' wages.
Tentevenityoudidn'tactuallywithholdtneia*'Fbrmoreinfoimation,callthe lnternal Revenue Service a'f 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCEFN: ,,. ..,!.r, ,-,, .: , ,,
Code Gompliance: Asthe permit holder for this project, you are responsible fer resolving any failure to meet
code requirements that'may.be brought to your attention thrcugh inspections.
Liability and Fropertyr Damage l*suiance: Contact your insulance agent to see ityou have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray, water damage from pipe punc-
lures, fire, or work that must be re-done.
.ir!'.r,r:-., l.r+f'r)".il '-i;:]!ilr;,filr1i' ,:i r "li:.r'.)"- : -,1 ..':.'t.
Time to Supervise'Employees: Make sure you have sufficient time to supervise your employees.
Expertise: 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.
lf you have additional questions, write to:Construction Contractors Board
700 summer st. NE, suite 300
Salem, OR 97310-0151
Phone 50&S/8-4621
NOTE: - This lnformation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passbd by the 1989 Oregcin Legislature.
o24N 10t24189