HomeMy WebLinkAboutPermit Backflow Test 2003-8-29
. CITY OF SPK1r~vFIELD
Building/Combination Permit
PERMIT NO: COM2003-00842
ISSUED: 0812912003
APPLIED: 08/29/2003
EXPIRES: 02/29/2004
VALUE:
.
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 5943 PUMICE PL
ASSESSOR'S PARCEL NO.: 1802033400109
TYPE OF ,WORK: Backnow Device
TYPE OF USE:
PROJECT DESCRIPTION: Backnow device
Owner: TERRY PROCTOR
Address: 5943 PUMICE PL SPRINGFIELD OR 97478
, CONTRACTOR INFORMATION I
Contractor Type
Plumbing
Contractor
OWNER
License
BUILDING INFORMATION I
OU \U
# of Buildings: # of Stoa~:,(es '1 \}\W\\'l
Primary Occupancy Group: R-3. c.fleigh~g~'ntCtl;'..ee\ IOt\
Secondary Occupancy Group: . , ':.; , . .\)\ u;eJYp'e\of.Th~!:a.(e S Z.OO'
Primary Construction Type \ IO-\VN .. a.oo? ~WatefOType:'fI.?> 95 leS \.
. ,..' 'u\e';:) {\P- '1"\\\V tU
Secondary Construchon Type: \Io~\j \ Cel\\e . Range';I'Ype:o' \"e ~e
W '01' 00")' nc' ,\ ,,0\'
# of Bedrooms: \IIICa.\\ 00'\- Energy,IPatb:e \ele? \101'
"'0 fl.?> 95Z- a.'l O'o\a.\\' ~o\e'. \~ ~o\IIICa.
,0 . '_I \ \1\ ..<>(. ~ . "..\\\'l ..
u09\J;W;1\9 I' DE~ELOPMENT.:'INFORMA TlON I
C pel ,- IS \ -
l\u\1\ cel\\e(
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
SETBACKS
Front yard Setback:
Side 1 Setback:
Side 2 Setback:
Rcaryard Setback:
Solar Setbacks:
% of Lot Coverage:
New
Residential
Phone Number: 541-747-3647
Expiration Date Phone
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Impervious Surface Area:
REQUIRED .PARKlNG
Total:
Handicapped:
Compact:
I PUBLIC IMPROVEJ\o.",,,.,, I
~O"i'\CE: ~'\f\'h'l!~fI1P\E. WORK
1HIS PERM\1 ~~~~~I'l9WilSjllili't\~~~01
f\.\J1HORI1.EO IS f\.Bf\.NOONEO 1'0
;~~~i~~~~ ~~R\OO.
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
I Valuation Descriotion I
Description
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Type of Construction
Total Value of Project
Paee 1 of2
Value
Date Calculated
.
. CITY OF SPRIl'\ju.H~LJJ .
Building/Combination Permit
PERMIT NO: COM2003-00842
ISSUED: 08/29/2003
APPLIED: 08/29/2003
EXPIRES: 02/29/2004
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
I Fp.p.~ tllW
Fee Description
+ 10% Administrative Fee
+ 7% State Surcharge
8acknow Device
Minimum/Adjustment Plumbing
Amount Paid
Date Paid
Receipt Number
$4.50
$3.15
$14.00
$31.00
8/29/03
8/29/03
8/29/03
8/29/03
2200200000000001459
2200200000000001459
2200200000000001459
2200200000000001459
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.
wiII be made the same working day, inspections requested after 7:00 a.m. wiII be made the following work
day.
l..Rp.ouirp.d Tn~o~
I 8acknow 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 carefuily examined the completed applicalion and do hereby certify that ail
information hereon Is true and correct, and I further certify that any and ail work performed shail 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 wiil be made ofany structure without permission of the Community Services Division, Building Safety,
I further certify tbat only contractors and employees who are in compliance witb ORS 701.005 wiil be used on this project.
I further agree to ensure that ail required inspeclions are requested at the proper lime, 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 wiil remain on the site at ail
times during construction,
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Owner or ContJ:ac\ol ~ "I~nature
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IF rJ" :;'CIIT'OF.sPR.INBEIEtD OREGdN",.'~,~1". :',:~~'
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22;' nrnl STR!:I7r . SFRINGrII:W, OR :17477 . FH:(;,41)72G,37;,3 . FAX: (;,41)72G<~G8:1
City Job Number CO"l/\ 200'3: - 00 J' '{ ~
Job Location '5 '7 43 ~ '^ VV\. : c...<= ~l
Assessors Mar UfO L. 03;' <-{ ( 0 0 I 0 '7 I ~ot ,tjI (,..3
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Owner I'" ~,..,' ~........,ck,r
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Addre<< 59'+3 p,^",,~('~ ~l&. C'.~
City 5P..{!t> DR.. qi l/- 7 ~ Statp
Phone 7 tf 7 - 3' Q
nuZ-. Zip q 7 l{:L9,
BACK FLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Administrative Fee)
COl/fracfor b~forll/afi01I
Contractor
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By signing this permit/applic~jOrf;i! ~gr;;eetQrcalb,(6r\l}Jinspection once the backflow prevention
d~vise ha~ been,installed an~J~yi,Si61~.f6r~(!!spt?SWlr((726-3769), I also state that all infonnation on
thIs permlt/apphcatlOnls c6rrect.\\\{\~ ,\o~" e~\'" '\
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Addrers
Zip
Expires
Date of Application
Checked for Delinquencip<
~
Checked for Historical Status
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Shared Drive (T:)/Building FonnslBacknow Preventionl-03.doc
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ConstructIOn Contractors Board
700 Summer St NE Suile 300
PO Box 14140
Salem OR 97309-5052
Phone: 503-378-4621
Web Address: www.ccb.state.or.us
Permit #: CDIM z.o.~ 008'1 ~
Issued by:
5'7((3 rvl.lM.l<..e
-:b rr Date: B"-Z" -0"]
Address:
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 app.vp.;ate blanks and initial boxes 1 and 2, and either box 3A or 3B:
~l.
ra- 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
~B. 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 about Construction Responsibilities on the reverse side of this form.
~'l. \ t~ ~)::J.q /03
(Signature of e a hcan!) (Date)
(White copy to issuing agency permit file, pink copy to applicant.)
L_.-..;,_owner.doc 03/11103
". . .
Adnnng m~ 1T~\lllIr (])wrrn GenneIrmll C~nn~Irmd~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.
,
Employer Respolllsibm~jes
You will, in most indtances, be ruled to be an "employer" and the contractors you contract with will be "employees" if
you use contractors rIOt licensed with the Construction Contractors Board to do labor in constructing or to assist in the
construction or impr9vement of a residential structure. As the employer, you must comply with the followiug:
,
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 Infonnation Center at 503-986-2200.
Unemployment Insnrance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes
on the wages of all employees. For more infonnation, 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 503-947.-7.815.
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 801-620-7.115,
O~her Responllsnlbinlities amB Areas of COnllcernlls
Code Compliance: As the pennit 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 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 of rough-in
and finish trades, and to notilY building officials as the appropriate times so they can perfonn 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.
Proper1y_owner,doc 03111/03
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2003-00842
COM2003-00842
COM2003-00842
COM2003-00842
Payments:
Type of Payment
CreditCard
"'~RtN.<<!'1J'LD._._. ...
~. ",
.';
"",."-~
Receipt #: 2200200000000001459
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Backflow Device
Minimum/Adjustment Plumbing
Paid By
TERRANCEPROcrOR
Received By
djb
Check Number
Balch Number Authorization Number
000156 029294
City of Springfield Official Receipt
Development Services Department
Public Works Department
Date: 08/29/2003 1:40:45PM.
Amount Paid
1Iem Total:
3.15
4.50
14.00
31.00
$52.65
How Received
In Person
Payment Total:
Amount Paid
$52.65
$52.65
.
.