HomeMy WebLinkAboutPermit Plumbing 1993-09-01CITY OF SPR"VGFIELD, OREGO'V
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
ISPBTNGFIELD
Office:
INSPECTiON LiNE:
726-3759
7 26-37 69
'225 Fifth Street
Springfie'ld, Oregon 97 477
Job Locati on :
Assessors a
0wner:
Addres s :
C'ity :
na ure
Date of Appl i cati on :
Receipt /i:
u-_-
FOR OFFICE USE
Phone #:
zi p:
Ex p'ires :
I
Tax Lot #
Phone #
Zi p:
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
Address:
C'ity :State:
Constructi o Contractors istration #:
t rr
/
By s'ign'ing this permit/application,
backflow prevention device has been
(726-3769). I also state that all
correct.
I agree to call for an inspect'ion once the
insialled and is visible for inspect'ion
information on this app'lication/permit 'is
J
a
Total Amount Collected:
Issued By
Job #
#:
State:
Tr+(
Permit No:
Address:
7-N:
1
2
lssued Date:
OR OFFICE USE ONLY
STATEMENT:
lNFORMATION 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 su6mit 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 r sale before or completion
A My ris
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 ra
lf I hire subco 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 contracto r 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 understandthe lnformation Notice to Property Owners about Construction Responsibilities on thereverse side of this form.
ature rmit t
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
3
OR
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
rlf