HomeMy WebLinkAboutPermit Plumbing 1995-05-16:r
SPFIt{GFIELD
BACKFLOI{ PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
%
225 FIFTH STRBET
SPRINGFIELD OR 97477
OFFICE:
INSPECTION LINE:
726-3759
726-3769
JOB LOCATION:
AS MAP #:TAX LOT *:
O\{NER:
ADDRESS:PHONE #:
C]TY:STATB:ZTPz
BAcl$Low PERMIT IS $15.00 + $.75 (STATE SURCHARGE) + $.45 (ADI"IIN. FEE) = $16.20
CONTRACTOR:
ADDRESS:PHONE #:
CTTY:STATE:ZTP:
CONSTRUCTION CONTRACTORS REGISTRATION #:EXPIRES:
BY SIGNING THIS PERMIT/APPLICATION, I AGREB TO CALL FOR AN INSPECTION ONCE THE
BACKFLOV PREVBNTION DEVICE HAS BEEN INSTALLBD AND IS VISIBLE FOR INSPECTION
(726-3769).' I ALSO STATE THAT ALL INFoRMATIoN 0N THIS PERMIT/APPLICATIoN IS
CORRECT.
f- /& -f5
DATE
FOR OFFICE USB
DATE OF APPLICATION:
fllcp1 ISSUED BY:RECEIPT #:
TOTAL AMOUNT COLLECTBD:2D
JOB *:
Permit #:
Address:
Issued by:Date: 5 \\o-qs
Statement: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires resi.denti.al construction perrnit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential butlding, 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 appropriate blanks and initial boxes I and2, and either box 3,{ or 3B
1. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
3,A,. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
3B. I will be my own general contractor
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
nzlme of the contractor.
I hereby certify thatthe above information is correct and that I have read and dounderstand the Information
to Property Owners about Construction Responsibilities on the reverse side of this form.
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applicant)
(White copy to issuing agency perrnit file,
pink copy to applicant)
OR
L (Date)