HomeMy WebLinkAboutPermit Plumbing 1993-10-08BACKFLOl,l PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPHii.GFtELo
0ffi ce:
INSPECTION LiNE:
7 26-37 59
726-37 69
225 Fifth Street
Springfield, 0regon 97 477
CITY OF OREGO'V
VV\Job Locati on :
As s es sors l,lap # :
0wner
Tax Lot #:
Phone #:
I
Addres s :
City State:
Backflow Permit is $15.00 + $0.75 State Surcharge
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Li p:
Contractor:-l
Phone #:
C'ity :State:Zi p:
Construction Contractors Registration #:Ex pires:
(C.dI?
By signing this perm'it/appf icat'ion, I agrgg to call for an inspectjon once the
backfio* irevontion dev'ice has Ueen installed and is visible for inspection
iTiO-g76g). I atso state that all information on th'is application/permit is
correct.
Datenaure
Date of Appf icat'ion :
Receipt il:
FOR OFFICE USE
Job #
Total Amount Col I ected :
Issued By
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q3l5.FPermit No:
Address
lssued Date:
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 t applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
1 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.
2
,L
OR
3.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.
3.8 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 inlormation is correct and that I have read and understand
the lnformation Notice to Property Owners about Gonstruction Responsibilities on the
reverse side of this form.1
gnature Permit Applica
CONSTRUCTION CONTRACTORS BOARD
0244J 8lg1
Date
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT