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Home My WebLink AboutPermit Backflow Test 2004-6-16 Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line . . CITY OF SPRINGFIELD' Building/Combination Permit PERMIT NO: COM2004-00712 ISSUED: 06/16/2004 APPLIED: 06/16/2004 EXPIRES: 12/16/2004 VALUE: SITE ADDRESS: 881 PRESCOTT LN ASSESSOR'S PARCEL NO.: 1703341409513 Springfield TYPE OF WORK: BackOow Device PROJECT DESCRIPTION: BackOow device TYPE OF USE: Owner: GREEN FRANCIS R & MELINDA A Address: 881 PRESCOTT LN SPRINGFIELD OR 97477 Contractor Type Plumbing I CONTRACTOR INFORMATION , Contractor OWNER License # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: . # of Bedrooms: Frontyard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Street Improvements: Storm Sewer Available: Speciallnstruclion: Notes: Description BUILDING INFORMATION' # of Stories: R-3 Height of Structure Type of Heat: '\0 VN WaterTYP~\~~~ RalJJ:l'\!fl>"e:'O~ ,~ O~.Od'f~d.)~~~O ~~;:;'\..st~~~ _ c~.,,~.J.~:;.\~~ '''r.,k\DEV.\l;U~JlMOO.dWIORMAlfI9rf 10 ~\'O'\\' I I ~U!'-' , r ... .. '" ". p.'6Q'" ~" ~'.",~ ~~ \i\O~ -:O\)~~ ~ ft~~~ ~ ~\\{I~\j'\~ISft~rl:~ ~ ~!!.~~rive Rqd: % of Lot Coverage: I PUBLIC IMPROVEMENTS' New Residential Expiration Date Phone Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft GaragelCarport Sq Ft Otber: Occupant Load: REQUIRED PARKING Total: Handicapped: Compact: Sidewalk Ty.ne;-~~ \NQ?''' ~\B.~jr \ S ~Q1 ~01\C~:. ~\1 s~~~~rtis~~~~~a\\ 1~\S ?~~l't.Q \}~Q~~ ~B~~QO~t.Q ~\}1~Q" Q Q? \" " r.C\~~~~Ct:~~ ?~?\QQ. ." \"" r I ....\., l Valuation Descriotion $ Per Sq Ft or multiplier Square Footage or Bid Amount Tvpe of Construction Total Value of Project Pallelof2 Value Date Calculated -iF . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-007I2 ISSUED: 06/16/2004 APPLIED: 06/16/2004 EXPIRES: 1211612004 VALUE: Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line I Fee~ Paid I Fee Description + 10% Administrative Fee + 7% State Surcharge BackOow Device Minimum/Adjustment Plumbing Amount Paid Date Paid Receipt Number $4,50 $3.15 $14.00 $31.00 6/16/04 6/16/04 6/16/04 6/16/04 1200400000000000917 1200400000000000917 1200400000000000917 1200400000000000917 Total Amount Paid $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. l..Reouired In~ne~tiow BackOow 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, and that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety. I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on tbis project. I 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 will remain on the site at all times~~n~ ~ /r, k ~,eo"..,(.. ".",ru. .... Pa~e 2 of2 225 Fift.h Street Springfield, Oregon 97477 541-726-3759 Phone . Job/Journal Number COM2004-00712 COM2004-00712 COM2004-00712 COM2004-00712 Payments: Type of Payment Check 6/16/2004 RECEIPT #: ~ JIily of Springfield Official Receipt '-elopment Services Department Public Works Department 1200400000000000917 DescrIption Minimum! Adjustment Plumbing + 7% State Surcharge + 10% Administrative Fee Backflow Device Paid By F RANDALL Received By djb Page I of 1 Date: 06/16/2004 Item Total: Check Number Authorization Batcb Number Number How Received 7230 In Person Payment Total: 2:05:02PM Amount Due 31.00 3.15 4.50 14.00 $52.65 Amount Paid $52.65 $52.65 . . , 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 #: .1'"0#1 w6 -D a "71 Z. -. . . . . " .. " .. " " Address: ~8'1 f IZ-~,-o +f- "b('\ {AI /, ~({, -01( Issued by: Date: 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 befiled with the permit. Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B: .-Z 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 thaI all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR A 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 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~t Construction Responsibilities on the reverse side ofthis form. /~,#',,~ _ k 1t6~c/ ~ "-(signature of permit applicant) . (D-ate)' (White copy to issuing agency permitfile, pink copy to applicant.) Property_owner.doc 03/11/03 .. . Adnllng ~~ 17mllJr ((J)Wll1l Gell1leIr~n C(fi)ll1l~Ir~d(fi)Ir? 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. 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. lEmployer lResponsilOmties 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 ill number, call the Business Information Center at 503-986-2200. , Unemploymen't 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, YOli: 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 503-947-7815. U.S. Internal Revenue Service: As an.~,:"ploy'er,y~u mu.st 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. . , . - . ."L '. . Other lResponnsiil):Hities amll Areas ofCollllcerlllls . , ,t! 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 Insuranee: 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 Sufe.,yo~ hay,e)l(ffici,ent time to supervise your employees. " . \ ~ -"- .::" , " ...-.- " " ~..' - - . Expertise: Make sure you have the skills to 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 call the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. Property_owner.doc 03111/03 . 225 FIlTH STREET. SI'R1NCnELD, OR 97477 . I'H:(54l)726-:n53 . fAX: (54 ])726-3689 ~: 0; .. ....-I' ~; ~. 0) Assessors Ma~ I 70"3, "'3 4/ L.( .,....-1. ~. ~: ~ ~:; ~': ~) .~ ' .. ~ ,) -- , ~ ~) ~~.ji CJ)) ~) .~ .\::I~ > ~ Cl ~j ~~ ~ ......-1< ~; ~l H~ ~ ~ ~ t_.1~ ~j ~ e;>J ~--:j ~. ,-.j ~l ~) ~> , ~ ~l Owner h i?a .....!.... U G--Q.. ., ~ J Address '3'~1 P~CA~o.JlL Phonp ?'l-b ~34'rb City-Sp (2.1~ p.& "tatp 0 R- Zip 97 '-f 7 "7 "t)9.'& Ii:. ..-- ;\ BACKFLOW PERMIT IS $52.65 (includes Permit F~~;\~~-.p.~arge & Administrative Fee) ~i-'? '?~'?-~\\ rcf;j'?- ~~. :\ ~",t>-\.\ '\"'\~ 'i)f;j~~'\) Contractor Information ~~'\'\ '?~'?-~\ \) ~~\)~':> ~'O~ I ,\"'\~",\),?-\1.~~\) \)~~f;j\)' Contractor N A ~~J"~*~~ <;l~ '? \~'{ \ 'OIJ _______ ----- Phonp ~ ~<;1) City / ~J(~~':~ZiP /.~ <oo~~q::. $\0 Construction Contractors ~~. ~~~~~Nil.~,",^~ Expires ~"tiW:~v -~ ~\- _.of<ll - .~^_- _ ~~~~O~~~;~~r By signing this pennitlapPliC~~~c:li,~~~~~the back flow prevention devise has been installed and is~1~~~169)~ I also state that all information on this pemlitlapplication is correct. :~~\:)~ ~~7 Signature. /. .'" .M. '" >/. .. . - "".. ~ City Job NumbcrCOWl z:..ooL\. -00 (I'Z. Job Location~tesz..S t;.,co-J.( lA-i'JO Addresg For Office Use Date of Application ~-(b -OLf SlPi::IlDNGIi=IG:1L.1Cl ,~ Tax Lot O~S(3 Oat.. ~h~ loci . . Checked for Delinquencie< ~hecked for Historical Statu< --- Shared Drive (T:}'Building FormslBacknow Prcvcmionlo03.doc