HomeMy WebLinkAboutPermit Plumbing 1992-09-21CITY OF SPRINGFIELD, OREGO'U
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPRINGFIELD
Offi ce:
INSPECTION LINE:
726-3759
7 ?6-37 69225 Fifth Street
Springfie'ld, 0regon 97 417
s 4qruJob Location:lL5i
As s es sors l'1aP ll :190 aos f,.t Tax Lot If :tr )cl al
Owner:T)nur (LE IN
Address:I TA Phone #: 'r1 zl
Zi p :?7 478: SPrcD State:cCity
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:r )L){2.
Address:Phone #:
Ci ty:State:Zi p:
Construction Contractors Reg'istrat'ion #: Expires:
By s'igning this permit/gpplication
bickfjow ptevcnt'ion dev'icc has bee
lzzo-:zoo1. I also state that all
correct.
. I aqree to call for an inspection once the
" ini[urled and is visible for inspect'ion
iniormation on this applicat'ion/permit is
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S 'r gna ure
Date of ApPlicat'ion:
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FOR OFFICE USE
Job #:
Recei pt ttz G')tQ,{ Issued BY:
Total Amount Col lected: \a 7S
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Permit No:a))l3at
Address:ll l,a s 4.ttu
lssued Oe Date:Q l.-,,1e>
OR OFFICE USE ON
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS701.055(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 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 ,
1
2
3
Contractor registration numbe r.
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
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 ! 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.
! hereby certily 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 ol this form.
-YiU-xff'?ler)q>
ffifpplicant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This lnformation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.gS5(S),
passed by the 1989 Qregon Legislature.
lf you are acting as your own contractor to construct a new home or make a substantial improvement to an
existing structure, you can prevent many problems by being aware of the following responsibiliti6s and areas
of concern
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the conslruction or improvement of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will be "employees". As the employer, you must comply with the following:
Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee wages at
the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the
tax from your employees. For more information, call the Oregon Department of Flevenue at 378-33g0.
Unemployment lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurancepur@mployees.Formoreinformatipn,calltheoregonEmploymentDivisionDHR
a|378-3224.
Workers' Compensation lnsurance: As an employel you are subject to the Oregon Workers' CompensationLaw,apensationinsuranceforyouiemployees'lfyoufailtoobtainworkers'
compensation insurance, you may be subject to penalties and will be liable for all claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434.
U.S. lnternal Revenue Service: As an employer, you must withhold federal income tax from employees' wages.
ymentevenifyoudidn'tactuallywithholdthetax.Formoreinformation,call
the lnlernal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be brought to your attention through inspections.
LiabiliU and Property Damage lnsurance: Contact your insurance agent to see if you have adequate insurance
coverage for accidents and omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure you have sufficient time to supervise your employees
Make sure you have the expertise to act as your own general contractor, to coordinate the work
and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
Expertise:
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0244J 10t24t89