The URL can be used to link to this page

Home My WebLink AboutPermit Plumbing 2003-5-16 -. .~ City of Springfield Plumbing Permit Status: Issued 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone 541-726-3676 Fax 541-726-3769 Inspection Line PERMIT NO.: ISSUED: APPLIED: EXPIRES: PLM2003-00027 5/16/2003 5/16/2003 11/16/2003 + 10% Administrative Fee + 7% State Surcharge Backflow Device Minimum! Adjustment Plumbing ~~'" ,~~ ~~'\ ~"\" {> (\<(.~ 0~'\ \)~ .J.~" c'(.". ~ <(. Receiot ~~&~~c., '~~~~ 22P0200~~~. ~ ~\@o~~~~~., ~~~~~~0~67" , " ~"\"~~~ ~~ ~ ~~~ ,~~ ..~ ~- To Request an inspection call the 24 hour recording at 726-3769. All inspections requested before 7:00 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following working day. 4104 Forsythia St 0 180205220340,g,\0~~{\'\ ~ c' ).\'\~ r>'\\ \.\0. Backflow~ifey.ll~e ~0 f"$), ~' 0'''-' :-.0 f):'V '0. ~ \'l). __0. ,. 0' _ (1\~' . ~c, $' '\.,. ~'O- :c' \)'- OWNER/APPLICANT: .O,\0C$r>0.'Q'\ e..e"~ ~O~\,~.rn'\ "",oPl.HMBING CONTRACTOR: ~. R\'cI ,<,0" ~($ 0"'" ~v ~\V MEYERS LARRY ~'\\O '0-0.0 0":' ()~,o ~\0~ 0\0\'0 ~,$j~WNER 4104 FORSYTHIA <\~ .s.0~ 0'\\~ R)~. cP'{' e'~ ~o . SPRINGFIELD OR 97!t'78 o~ '\ . 0'\\ G f:::J()'\'c::J ~\qy:.'\\ ~o'\'; \J~{\:?"f!.'t>.~ \O\"'K\vr6:-~~7: ~'lJ:~ 0 ~\e'\' ~o'\\ ~ro?: ~O~orr--<<-_,o'V eve 0,,0 ~$()" . ~ t'o ~ ~ ~e \' "\ R)9:J'V' ~\'\\~ ,\0" '5.\~ c::J CJ~ ,^e" "l'>~\.e ~'I."'" 'V ~ Amount Paid SITE ADDRESS: ASSESSOR'S PARCEL NO.: PROJECT DESCRIPTION: Springfield TYPE OF WORK.: TYPE OF USE: New Residential CCB# EXPIRES Descrintion Date Paid 4.50 3.15 14.00 31.00 05/16/2003 05/16/2003 05/16/2003 05/16/2003 Reauired Insoections: 1 Backflow Device: Prior to covering and provide a copy of the test report on site at the time of inspection. By Signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances of the City of Springfield and the laws of the State of Oregon pertaining to the work described herein. I further certify that only contractors and employees who are in compliance with ORS 701.055 will be used on this project. I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the street, and that the approved set of plans, if applicable, will remain on the site at all times during construction. ~~~' O~r or c6ntradbrs Signh1ure s- --/~lJ3 Date Date of Application '(~~J Checked for Delinquencie~ ~; ~' ~"""'" ~.-'; .. ",J, ~,'.,','"",.),.,.,,',' _', "<' A$ m\ ~~ :~':~=.tj p.\ " ~,..,...,.,..'. ~ L~/ "" .It 51 ~, (t), <"', "- ", ; __ {::'f ~i," ~.~ 1'1;'" ~~ ~c "-Co' ,. "j'{ ~.. ~/ ~, ~: ~:J .... h ,J* I~,_! ~. ~: ~ ~r' ~ ~, ~.. ~, ~ . ZZ5 FIFTH STREET.. SPRINGFIELD, OR 97477 .. PH:(541)7Z6.3753 .. FAX: (541)726.3689 0Lf/1/1 2(')0 ~ - 000 z. ( City Job Number Ii _ Sf- Job Location if/a Cf foY5::-.t/Jo.- fjrr Assessors Mar I 00 L. 0 S- z z Tax Lot 03LfDO Owner !-tJ-I~ /1~er5 Address L; 10 Lf r; r5<;'\fI,;o-- f) r', ...... City 31' I ~ p/etr{ .-\\.. 'NQ~~ Statf' 0 e I ~ \~,~ ~ ~\)\ -'fO\~t. _''"'-t-~\"\ ", l.1r. . ~\.. t. ,. \>t.' \\ \'\J\' BAc~~d':~~~~'~~~~~udes Permit Fee, State Surcharge & Administrative Fee) ",S \>t; It.~ ~ ,S \\~ "\ :\,,\j~' x.~ (J~ ~(J~' COlltracto}'fn~~~ ?t.~ C\J "j ,\ro~ \\~, Contractor Phonf' 7~~or~g Zip (j'7t/?o Addrefs .rIL tiO' OJ Phonf' City State Zip Construction Contractors Registration # Expires I\'r--!"-.. . . .. . -.. "'-" ".VI t::YUIl jaw reqUires you to . fo~l?w rules adopted by the Oregon urn ' B .Notlflc8t.,tion Center T.bo<:'(.:I rIJ/iPC' ,.,....n.<+~tl./ {1~!C . . h b kfl . Y S];~~.g-tJys;p.eI~tl1saPMl'catronf.tagt'Gc~lg crud lllor an InSpectIOn once t e ac ow preventIOn devi~p,rh;s"biee~ i~"tJiie~ anfdlmlv~siQ&%~!FRnp'€b1ion (726-3769). I also state that all infonnation on ~~v. va mav ooram conies f th " this pennit/ap,.ol.lcation is cQr.fecL. 0 e ru es b} "''''''".!:; lflt:: <.;snteL(Note: the telephone number for the Orego, ~Uti . Y , tification , . c~~n,vris1-8n 3._-2 _ ' SIgnature --r- A d 5~/b'o3 DatI". For Office Use S;0~ V v- Checked for Historical Status Shared Dlive (T:)/Building Fonlls/Backflow Prevention ].03,doc , - . Construction Contractors Board 700 Summer St NE Suite 300 PO Box 14140 Salem OR 97309-5052 Phone: 503-378-4621 Web Address: www.ccb.state.or.us Permit #: ?Lmz.OO~OOO z 7 Address: L{ ( 0 L{ ~s.y-/.. ~ l A '5>1- S// t.k I / I Issued by: )) ~ Date: Statement: Info. mation Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not licensed with the Construction Contractors Board to sign the following statement before a building permit can be issued. This statement is required for residential building, electrical, mechanical and plumbing permits. Licensed architect and engineer applicants, exempt from licensing under ORS 701.010(7), need not submit this statement. This statement will be filed with the permit. Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B: >> 1. ~2. I own, reside in, or will reside in the completed structure. I understand that I must become licensed as a construction contractor if the structure is sold or offered for sale before or on completion. o 3A. My general contractor is (Name) (CCB #) I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR % 3B. I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will contract with a contractor who is licensed with the CCB and will immediately notify the office issuing this building permit of the name ofthe contractor. I hereby certify that the above information is correct and that I have read and do understand the Information Notice to Property Owners about Construction Responsibilities on the reverse side of this form. ~~J? ~ 5~/6--o~ ?7 tslgna6:{e of permit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant.) Property- owner. doc 03/11/03 . -. Acting as Your Own General Contractor? INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES 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. I 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 concerns. Employer Responsibilities You will, in most instances, be ruled to be an "employer" and the contractors you contract with will be "employees" if you use contractors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the construction or improvement of a residential structure, 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 a State Business ID number, call the Business Information Center at 503-986-2200. Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488. 'Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you could be subject to penalties and be liable for all claim costs if one of your employees is injured on the job. For more information, can the Workers' Compensation Division at the Department of Consumer and Business Services at 503-947-7815, U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the tax payment even if you didn't actually withhold the tax. For a Federal EJN number, call the IRS at 866-816-2065 or fax them at 801-620-7115. Other Responsibilities and Areas of Concerns 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, Liability and Property Damage Insu.rance: Contact your insurance agent to see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or work that must be redone. Time: Make sure you have sufficient time to supervise your employees. Expertise: Make sure you have the skins~o act as your own general contractor, to coordinate the work of rough-in and finish trades, and to notify building officials as the appropriate times so they can perform the required inspections. If you have additional questions can the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. Property _ owner,doc 03/11/03 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone City of Springfield Development Services Department Public Works Department Official Receipt ' Job/Journal Number PLM2003-00027 PLM2003-00027 PLM2003-00027 PLM2003-00027 Payments: Type of Payment Cash Change Job/Journal Number PLM2003-00027 PLM2003-00027 PLM2003-00027 PLM2003-00027 Payments: Type of Payment Cash Change 5/16/2003 Receipt #: 2200200000000000867 Date: 05/16/2003 Description Backflow Device Minimum! Adjustment Plumbing + 10% Administrative Fee + 7% State Surcharge Amount Paid 14.00 31.00 4.50 3.15 $52.65 Item Total: Paid By LARRY MEYERS LARRY MEYERS Received By djb djb Check Number Confirm No How Received In Person In Person Payment Total: Amount Paid 52.75 (0.10) $52.65 Description Backflow Device Minimum! Adjustment Plumbing + 10% Administrative Fee + 7% State Surcharge Amount Paid 14.00 31.00 4.50 3.15 $52.65 Item Total: Paid By LARRY MEYERS LARRY MEYERS Amount Paid 52.75 (0.10) $52.65 Received By djb djb Check Number Confirm No How Received In Person In Person Payment Total: 2:12:30PM Page 1 of 1 -. . cReceipt.rpt