HomeMy WebLinkAboutPermit Backflow Test 1993-11-9
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SPRINGFIELD
BACKFLOW PREVENTION OEVICE PERMIT APPLICATION
CITY OF SPRINGFIELO
BUILOING SAFETY OIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location: '2yQ0 ))E7J(;(C
Assessors Map ": /~t93 3..\ 2- J
Owner: ~77?1/G MpKIAJS
Address: 2.:2 72 fA/(' /,fJrl-/;JtV) C7,
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City: br48UcState:
Office: 726-3759.
INSPECTION LINE: 726-3769
Tax Lot ": -1;;2...0 l)
Phone U: ~ fG c;- -.:77/l ,-
~, Zip: 974/.J"'U
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor:
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Address:
City:
State:
Construction Contractors Registration U:
Phone U:
Zip:
Expires:
By signing this permit/application, I agree to call for an inspection once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct. .
FOR OFFICE USE
Date of Application:
/1-5'-)'3
Receipt II:
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Issued By:
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Total Amount Collected:
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Job U: CJZ/490
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Permit No:
92/490
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;".~ Date: 11-9-'13
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Address:
Issued by'
FOR 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 the applicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
1. p..c::- J
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I own, reside in, or will reside in the completed structure.
2.~1
-
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
3. A.I
I 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.'
OR
3. L-~ I ! will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. If 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 contr,!ctor.
I hereby certify that the above information is correct and that I have read and understand
the Information Notice to Property Owners about Construction Responsibilities on the
rev, erse sid,e ot"th~i1S form.
F,4L-.!" ~ '(
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- /,81grfa'Wre mtpe(m1t APplicant Date
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CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
. .
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
.I' . r ..
NOTE: . This Information 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.
If 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 responsibilities and areas
of concern.
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvamsnt 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 Tal( Law: AS an employer, you must withhold income taxes from employee wages at
the time employees am paid, You will be liable for the tax payments even if you don't actually witi,hold the
tax from your employees. For more information, call the Oregon Department of Revenue at 378-33S0.
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemploymsnt insurance
purposes on the wages of all employees. For more information, call the Oregon Employment Division DHR
at 378-3224.
Workers' Compensation Insurance: As an employer, you are subject to the Oregon Worxers' Compensation
Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers'
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. Internal Revenue Ssrvice: As an employer, you must withhold federal income tax from employsss' wages.
You will be liable for ths"ta:t"payment even if you didn't actually withhold the tax. For more information, call
the Internal Revenue Service at 221-3960.
On-lER RESPONSISH..ITIES AND Af'lIEAS OF CONCE~N:
~ode Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may b~ brought to your attention through inspections.
Uabiliiy and Property Damage Insurance: 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 Employess: Make sure you have sufficient time to supervisa 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 trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
If you have additional questions, write to:
Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
0244J 10/24/89