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Home My WebLink AboutPermit Backflow Test 2005-10-20 '. . CITY OF SPRINGFIELD I Building/Combination Permit PERMITNO: COM2005-01472 ISSUED: 10/20/2005 APPLIED: 10/20/2005 EXPIRES: 04/20/2006 VALUE: Status: Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 1710 RAINBOW DR ASSESSOR'S PARCEL NO.: 1703273100100 Springfield TYPE OF Backflow Device PROJECT DESCRIPTION: Install backflow device TYPE OF USE: New Residential REQUIRED PARKING Overlay D1st: 0') ~{\\)Total: # Street Trees ~ ~0\U 0\ ~0o:. ~\~~~dlcapped: Paved Drive Rqd: R)'O\ '0, 0~~ ~\ 'Ou, .td6'&.aet: % of Lot Coverage;.,CU"'.(l 'l;;0~0 \)0') 0 ~ {\O'r-,\,<.o ~\ 1;v \)0 .~0'\ jo.-e . ,;-;'0 ~ ~'Ii'\,o\' .\"J{O t"""'\,"',,,~ ."....0,0 . ,,~'V ./'O.\\-e') '_,,0\ IPUBLIC IMPROY~N:rS";\~P')'~'()\.~~0\\)0') ~0~~ ~::.,,~~ " \,' O~" . ,,-e \\".-- \r o\O,v ~,~ .,'0'0 Sm~~;}TY ,:-0\>- 0>S ~0 0'"' "'_ _ Y.P!; 0\{\ ',)"\\ ~~ \--0. ~'00~U \--0.'" ,1.tS'O 0~-e ",0~ eD'o~~pontslDralns .\.()~ \0'" 'l;;0~0 0~ ll' ~o\ ",0 ~{\'O ~ \--\'~'I."'0\--",0~' 0\'0 . Owner: JOLENE HA TION CHILDREN'S TRUST Address: PO BOX 71573 EUGENE OR 97401 -" Contractor Type Plumbing I CONTRACTOR,lNFORMA:TlON I , ii. WIll 9\~t. " \\ \<;, 'w ' C?~\\ttief,'. \\ S\\r>,\.\. ~{\\\<;, '?t.~WI\) t()~ License OW;~~ PJ.~\-lit.: 1\~9t.~ ..:J"m()~t: t>.\,}\'t$)?-~~Ct.~ BrnRfG INFORMA nONI ()~\lI~" ra..'t ~lt'l Ct>.~'4 '\'O$ 'i) # of Stories: 'k-3 Height of Type of Heat: Water Type: Range Type: Energy Path: Sprinkled # of Units: Primary Occupancy Group: Secondary Occupancy Yrlmary Construction Type, Secondary Construction # of Bedrooms: VN nla , DEVELOPMENT INFORMATION I Front yard Sethack: Side 1 Sethack: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Storm Sewer Available: Speelallnstruetion: Notes: I Valuation Descriotion I Description $ PerSq Ft or multiplier Square Footage or Bid Amount Type of Construction 1 of 2 Phone Number: 541-206-7596 Expiration Date Phone Lot Size: Sq Ft "Ist Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: Valne Date Calculated ~iii'. . . CITY OF SPRIN\.Jl'lliLU Building/Combination Permit PERMIT NO: COM2005-01472 ISSUED: 10/20/2005 APPLIED: 10/20/2005 EXPIRES: 04/20/2006 VALUE: Status: Issued 225 Fifth Street, Springfield, OR S41-72~3753 Phone 541-726-3676 Fax 541-726-37691nspectIon Line Total Value of Project L.FI'I'S Paid I Fee Description + 10% Administrative Fee + 7% State Surcharge Backflow Device Minimum/Adjustment Plumbing Amount Paid Date Paid $4.50 $3.15 $14.00 $31.00 10/20/05 10/20/05 10120/05 10120/05 Receipt Number 1200500000000001578 1200500000000001578 1200500000000001578 1200500000000001578 Total Amount $52.65 I Plan Reviews I To Request an inspection call the 24 hour recording at 726-3769. All inspection 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 work day. I I?Pn~ Backflow Device: Prior to covering and provide a copy of the test report on site at the time of inspection. By signature, 1 state and agree, that 1 have carefully examined the completed application and do hereby certify that all information hereon is true and correct, and 1 further certIty 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, and that NO OCCUPANCY win be made of any structure without permission ofthe Community Services Division, Building Safety. 1 further certity that only contractors and employees who are in compliance with ORS 701.005 will be used on this project. 1 further agree to ensure that all required inspections are requested at the proper tIme, that each address is readable from the street, that the permit card Is located at the front of the property, and the approved set of plans wiD remain on the site at all tIme~ during const/~OIL cf\ \ l f'J .f<.--} tT-- \ t:1. h.'"\ 1,,( "- ~ \ ()/ ';:jn/ n;;;- '- Owner or Contractors Signature Date 2 of 2 I); \, .l ". " ". ." , .' . Construction Contractors Board 700 Summer St NE Suite 300 PO Box 14140 Salem OR 97309-5052 Pbone: 503-378-4621 Web Address: www.ccb.state.or.us Pennit #: COWlL.r-" 1'-i7 Z. /7/0 \2A-~ ~L --:o<S' Date: /0 ~ 2-0 -0 J Address: Issued by: Statement: Information 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. 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! 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 of the 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. ~IJ-~~' ~} /f\".^ldo,_ . , (SI&>.",......: ofpeImlt applicant) In/~B/~ (Date) (White copy to issuing agency permit file. pink copy to applicant.) Property_owner,doc 06-01-04 , . A~~nlIll~ ~~ lttillIr ([))wrrn GtelIllteIr~n C(jJ)lIll~Ir&l~~(jJ)Ir? , . INFORMATION NOTiCE TO PROPERTY OWNERS A180UY 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, .. 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. , lEll1I1l/PllloyteIr Rte!l/Plorrn!lJil'o1m~nte!l 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 WiihhOlding Tax lLaw: 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 Department of Revenue at 503-378-4988. 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. The Oregon BU$iness Identification Number (BIN) is a combined number for both Oregon Withholding and Unemployment Insurance Tax, To file for a BIN, call 503-945-8091 or www.dor.state.or.us/formsnav.htmlI for the appropriate forms, Workers' Compensation llnsnrance: 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 ~~uld 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 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 EIN number, call the IRS at 1-800-829-4933 or visit their web site at www.irs.l!ov, (())~llnteIr Rte9/Pl<lJ>ll1l9ftlbfillfill:nles ~ll1la:ll AIrIe~S o1T C<lJ>ll1l\Clelrll1l!l 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, lLiability and !Property DllIDege 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 have sufficient time to supervise your employees, Expertise: Make sure you have the skills to act as your own general contractor, to coordinate the work ofrough-in and finish trades. and to notify building officials as the apt" vp' ;ate times so they can 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_own,er.doc 06-01-04 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone . ~: ~ty of Springfield Official Receipt .velopment Services Department Public Works Department Job/Journal Number COM2005-01472 COM2005-01472 COM2005-01472 COM2005-01472 fiyments: T:/pe of Payment C,editCard .' " , :i 10120/2005 RECEIPT #: 1200500000000001578 Date: 10/20/2005 Description + 7% Slate Surcharge + 10% Administrative Fee Backflow Device Minimum! Adjustment Plumbing Paid By MIKE GAMBLE Received By djb 1 of 1 Item Total: Lheck Number Authorization Balch Number Number How Received 172535 In Person Payment Total: II :22:05AM Amount Due 3,15 4,50 14,00 31.00 $52.65 Amount Paid $52.65 $52.65