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Home My WebLink AboutPermit Plumbing 2003-5-21 ~:!' 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: PLM2003-00031 5/21/2003 5/21/2003 11/21/2003 SITE ADDRESS: ASSESSOR'S PARCEL NO.: PROJECT DESCRIPTION: 140 ALLEN AVE 1703233300212 Install backflow device Springfield TYPE OF WORK: TYPE OF USE: New Residential OWNER/APPLICANT: LACOCK JAMES A & JuDITH M 140 ALLEN AVE SPRINGFIELD OR 97477 PLUMBING CONTRACTOR: OWNER o..*,- CCB# ~(;:>" ~ .~, ~\:) ~"v 'V Descriotion ' Amount ~id# ~e Paid + 10% Administrative Fee , -;$~~~4Y <<. OS/21/2003 + 7% State Surcharge ,,<<; ~~:J~' OS/21/2003 Backflow Device ~ ~ ~'A.~ OS/21/2003 Minimum/Adjustment Plumbin~ ~ S~ ~<\)~ S ~.OO OS/21/2003 ~f\j ~<<;-~\<\) -\S \:)'<- ~\:)~. ~~ ,,,S (( .,,~~,\.~ ~ ~~ " '\.,. ~''(,\~'<..-.~- ~-<- ,0 To Requ~st an inspection cal~~1tR~recording at 726-3769. All inspections requested befo~e'l'~:Q~~'"1' will be made the same working day, inspections reque~~er 7:00 a.m.'will be made the following working d, ay\>\,\0~ ~ '0~ ~,o~ ,_ r r.>~ _(\0 e,0 C'\~ . ~' O'~' ~'O 6v v' ReQuired InsDections:' 0"\'0- >is'0 ~0~ ~'?'-<(-. OJ ,\~0~0 1 B ktl D. p' t . d "d f th t <,tl~<:f> ~ ~t l'\ r.-.t'{ "f\()t'h 't'(\0 "'fO ,"~. \ ac ow eVlce: nor 0 covermg an provl e a copy 0 e e~'reR.9I1 on:sl ~~ e\lm~(() 'mspectIon. O~. (oo...c~ "\~v ~O . ~ \J ,0~ ~~\G<> By Signature, I state and agree, that I have carefully examined th~'J:~1lI:91ef~~S~RP~i:c'ID\O!l~~dSdll\,er.~~ certify that all information hereon is true and correct, and I further certif~ t~(aY"'ar&~nd':'KIl'~o~~e.erf()Iiw~~~1i~Il...btel';.done in accordance with the ?rdinances of the City of Springfield and the la,,:s of the~~{tt~~~b~0't~~~,fSdil!~!I~e~h~~.97k des.cribe~ herein. I further certIfy that only contractors and employees who are m complIanseCwltlj'OR:,S.qOk055)~m,te.)used on this proJect. I further agree to ensure that all required inspections are requested at the pr~~edifue,~tfi1t~~ac'h\lfd~re~~is readable from the street, and that the approved set of plans, if applicable, will remain on the site jit'albtimes~li'uning ~oJi~truction. , ~,,- ':IF" ~ ,- :<::-'''' , v ~~'O0 CI6 \\ EXPIRES Receiot Number 1200200000000001281 1200200000000001281 1200200000000001281 1200200000000001281 ()~m\~ ~er or Contractois-'Signature ~/;;L';:' 3 Date/ 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number PLM2003-00031 PLM2003-00031 PLM2003-00031 PLM2003-00031 Payments: Type of Payment Check 5/21/2003 City of Springfield ' Development Services Department Public Works Department Official Receipt Receipt #: 1200200000000001281 Description + 10% Administrative Fee + 7% State Surcharge Backflow Device Minimum! Adjustment Plumbing Paid By JAMES LACOCK 1:15:39PM Received By djb Date: OS/21/2003 Amount Paid Item Total: 4.50 3.15 14.00 31.00 $52.65 Check Number Confirm No Amount Pa.d How Received In Person Payment Total: 52.65 $52.65 Page 1 of 1 cRcccipt.rpt 0< 0, , <,,' .,,,...;..;{ """""'4 ~"" P "h.,., \"",."II"-j ..~; 1i; ,~\ < , .............: .,~i S; ~; ~; f!'!'\.,\ . ~-: CJ)1 0, .,} ,~,-,t; ~.", "'1'\'. ~ h=d, ~~ ~; ~-I .,~~ ~. t:: .-!,Y \V'' >. ~. ~, ~, ~0 ~ 0, r--di \'.J,:.T l: ....' ~' f~,..",r~ \~i ~' ~'" ~~ 225 FIITH STREET. SPRINGFIELD, OR 97477 . PH:(54-1)726-3753 . FAX: (541)726-3689 City Job Number f LtAA ZOO 3 -0 C:> 0"3 I Job Location /t/o 4//elJ it; fL. "\fJ}/d j 70 "3 Z 33.-~ Tax Lot 00 '?,j z... Assessors M;:lp Owner J t1. /h es ~.' .Jd/;J. '- a..,Cd c/e...- Address /~tJ 4;/~ 4v-e- 716 '~771 , Phonf' City ~a r:/J u Zip q 70'17 Statp (!)~ BACKFLO\V PER1VUT IS $52.65 (includes Permit Fee, State Surcbarge & Administrative Fee) ~~ ' &,~\S~'0'\ Contractor Information ~ '\~ ~ {o c. ~' ~ ~~,.. ~~ ~<v~ &,~ ~L-VAI&-<2--.. \~,,~~ '0-~~ -x-.~v ~ ,. ~~,.. ,~~~~ :~~~~~ ~~. ~,. ~'\.... \.\) '0\.... ~v ~ ~~ <;), ~~"C r;..,<V~ ~<v~ City -<..: ,0..~ ,~~ -~ ~'V L~~\V ~ \,)' <0~' ,CQ Construction Contractor~~stration # Contractor Address Phonf' Statp Zip Expires , 0 ~~ ~ By signing this penl1it/application, I agree to call for a~:I'm.~Be'etiq,n once the backflow prevention d~vise ha~ been ,ins~alle.d and is visible for inspect~Q.tl''YJ~~~~(.o91.)c)1' also state that all infonl1ation on thIS penmt/apphcatlOn IS correct. '(>~' e 0'<:. ~e oJJ~ ~e'?:J ~ ' \),,\ ~ ~e'?:J ~~ ~-v. 10e ' o~ 0.'0'\ e" ~O ~e ~o .o~ Q _ , / _#J/ /),\",,~j~,0 ,\~OCd t..O-V~ ~ 0' ,rt-e~~\V~ ! I Signal e ,- ,,/ dA& "'1 ~,.. ~ iI$' .o.<:i"..'f:'e ~,c'<;i Date S- ,;).I( & 3 - , '-. \ v' ~.$-e':) (p~ v(J(J" ~~ ~o,e'\~~~ 0Jb.l>iV y..' \.o~ ~o~ \0<0 0'9'\! ~ ~ 10 \) n.,f7:'?,.' lto\\' d'~O: ~~'?: ..t;1),'\ ^-,e' ,."e:,O ,.,,!:). ~o~~~:~o~ ~8.~€>~~~e<tU~e \" R>V .~.., &0' e" ('\.(5 ""\::::." t>>\' ~,!<:' -: /. G~\.4Pv C e 5/ l-<;.y a >1 , f Date of Application Checked for Delinquencif"" .,-- v- Checked for Historical Status Shared Drive (T:)lI3uilding Fnnns/Backnow Prevention I-03,doc .. 4.. . 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 #: yLW\ '2003 -()OO3 \ "J 4 0 . ALLtf\!' Ave Da Date: 5/z.(/D~ ., / Address: Issued by: Statement: Inf91 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 I 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. D 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 ' .', X 38. I will be my own general contractor. If I hire' subcontractors, I wili hire only subcontractors licensed with the Construction Contractors Board. If! change my mind anci hire a general contractor, I will contract with a contractor who is licensed with the C,CB 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. . O~j~-4t ~ . .. ... . :;-;';"';"3 lX- (Signature of permit applicant) (Date) . (Whfte copy to issuing agency permit.file, pink-copy to applicant.) Property- owner.doc 03/11/03 ., ... .. , ' Act_~g ~~ X o~r Own General Contractor? INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES NOTE: This Information Notice to Properly 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 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 th~ 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 Busin~ss 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"call the Workers' Compensation Division at the Department of Consumer and Business Services at ?03:-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 EIN 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 Insurance: 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 h~ve sufficient time to supervise your emp~oy~es. \ " , , I Expertise: Make sure you ha~e the skills to ac.t as your own general ~ontractor, to coordinate the work of rough-in and finish trades, and to notify buildingofficia1s'as the appropriate times so they dm perform the required inspections, If you have additional questions call 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