HomeMy WebLinkAboutPermit Plumbing 1990-07-24..-
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRiNGFIELD
BUILDING SAFETY DIVISION
ISPFITTIGFIELE'
0ffi ce:
INSPECTION LINE:
726-3759
7?6-3769225 Fifth Street
Springfield, 0regon 97 477
CITY OF OREGON
099 South 44th, SPringfield' 0R 97 478-7507
1Job Location:
Assessors MaP #:
0wner:Julie & Dave hJilson
Address: 1 099 South 44th Street, SPfld
City: Springfield, St
Tax Lot #:
Phone #:726-1068
ate: 0R Zi p:97 478-7507
Backflow Permit is $15.00 + $0.75 State Surcharge
Ot^lNERContractor:
Address:Phone #:
City:State:Zi p:
Construction Contractors Registrat'ion #: Expires:
By s'igning th'is perm'it/qpplication, I agree to call for an inspection once the
backflow preventlon devit'. nas neen insl,alled and is vis'ible for inspect'ion
iTZO-g76gi. f atso state that aii information on this application/permit is
correct.
3 lqc
gna re
Date of App I 'icati on :
Receipt #:
FOR OFFICE USE
Total Amount Collected:
Issued By:
. Job #:
Permit No:
Address
lssued Date
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential building permit applicants
who are not registered with the Construction Contractors Board to sign the
following statement before the building permit can be issued. Liiensed 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 applicable blanks, and initial box 1 and either box 2A or 28:
1.fA lown, reside in, or will reside in the completed structure.
2, A,My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
OR
i(oirl ia)i fr,rl
fr\\-
;14
L
COPY TO ISSUING AGENCY PERMIT FILE
SNTGCOPY TO APPLICANT
B d I will be my own general contractor.
lf I hire subcontractors. I will hire only subcontractors reoistered with theConstruction Contractors Board. lf ! chanoe mv mind and Eo hire a oeneralcontractor, lwill contract with a contrattor'who is reoistered with theConstructibn Contractors Board and I will immediately-notifv the officeissuing this building permit of the name of the contraitor. -
I hereby certify that the above information 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.
{Sig6a[ureoffi te
CONSTRUCTION @NTRACTORS BOARD
024N 10l24lp DrN
\,I/I{+TE
(^}1\1,
@s
etw
q0
,-
-t