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