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HomeMy WebLinkAboutPermit Plumbing 1993-06-24CITY OF SPR'A'GFIELD, OREGOA' BACKFLOI,J PREVENTION DEVICE PERMIT APPLICATION CITY OF SPRiNGFIELD BUILDING SAFETY DIVISION SPRI]{GFIELD Offi ce: INSPECTION LINE: 726-3759 7 26-37 69 225 Fifth Street Springfield, Oregon 97 477 ,ry-Job Locat'ion : Assessors MaP #' , <Qcz-?l/ rax Lot #:1>c'72 0wner: Addres s : C'ity :State: Backflow Permit'is $15.00 + $0.75 State Surcharge Contractor : Phone #: 2 -2>aa 7-ipt a7u-> Phone #: City:State:7-ip: Constructjon Contractors Registratjon #: Exp'ires: t:",.' By.s,igning this perm'it/applicat'ion, I agrgg to call for an_ins-pect'ion once the bickfio, [revention devit'e fras been insta'lled and is v'is'ible for inspection (726-3769). I also state that all information on this app'lication/permit is correct. b-; y- ?3 gna ure DaEe FOR OFFICE USE Date of App'lication:6-2/-9V Recei pt *: V?/ Issued BY: Total Amount Collected:T Job #: Permit No:?7re Address: lssued by 1 2 R 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 underORS 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. 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 Construction Responsibilities on the reverse side of this form. l-z/ -qsgnaturermitpplicantDate - CONSTRUCTION CONTRACTORS BOARD 0244J 8191 Date WHITE COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT 3 OR INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES tf you are acting as yo ,1 ur- own'contractor can prevent mdhyexisting structure, you of concern. lf you have additional questions, write to: to conStruct a new home or make a substantial imprOVement to an problems by being aware of the following responsibilitles and areas EMPLOYER RESPONSIBILITIES: lf you hire persons not registered with the Construction Contractors-Board to do labor in constructing or assisting in the construction or iriprovdment of a re6identialrstructure,'you wili, in most instances, be.ruled to be an ,,employer" and the peopje Vpu hire will be "enrployees". As thd'emplole.r, you'must comply with the following: Oregon's Withholdilg Tax Law: As an employer, ygu must withhold income taxQs. tr91 elOJ.oyee wages.at uwiltbeliabteforiheta5paymentSeVqnifyoudonitactuallywithholdthe tax from your employees.' For more information, call the Oregon Department of Revenue at 378-3390. Unemployment lnsurance Tax: As an em ployer, you are required to pay a tax for unemployment insurance For more information, call the Oregron Employment Division DHRpurposes on the wages of all employeqs. at 378-3224. Workers' Compensation lnsurance: As an ernpkryer, you are subiect to the Oregon Workers' Compensation pensationinsuranceforyouremployees.lfyoufailtoobtainworkers, compensation insurance, you rnay be subject to penalties andiwill.be liable for all dtaim costs if one of your employees is injured on the job. For more information, callthe Workerq'_Cgmpensation Division DIF at 973-7434. U.S. lnternal Revenue Service: As an employer, you 4ust withhold federal incom.e.tax from employees'wages. ymgnteveriifypl,didh'tactuallywithholdttreteii..Formoreinformation,call the lnternal Revenue Sdrvice at 221-3960. : . OTHER RESPONSIBILITIES AND AREAS OF CONCERN: Code Compliance: As,the permit holder for thls project, you are responsible for resolving any failure to meet code requirements that may be brought to your attention,through inspections. Liability ar{d Froperty Damage lnsuralrce: Contact youir'irisurance agent to see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint ove rspray, water damage from pipe punc- tures, fire, or work that rnust be re-done. Time to Sup ervise 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 tradeg, and the required inspections. to notify building officials at the appropriate tirnes so they can perform Construction Contractors Board 700 Summer St. NE, Suite 300 Salem, OR 97310-0151 Phone 503-378-4621 NOTE: This'lnforlnation Notice to Property Owners About Construction Responsibilities was developed by the Construction Contractors Board in accordance with ORS 701.055(5), :passed by the 1989.Oregon Legislature. o244J 10t24t89