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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, ~~Q,- (_ _ )An~ .........., ..I Owner or ContJ:ac\ol ~ "I~nature 8)~9Jo3 Date Pa!!e 2 of2 o o '-~ ~ Ci:S. U .~ ~ ~, ~. <e:' ~ .,~ ..... .... ..... ..... 0): ~ QJ).' u .~, '>: (lj); 0, 0: 0; . ~. ~: 0: (1); ;>. 0); ;.... , ~: ~.~ 0) ~; ~: 'U; ~: ~~ . . IF rJ" :;'CIIT'OF.sPR.INBEIEtD OREGdN",.'~,~1". :',:~~' J.,'ti :'" + ,\,~ v,~ '. " l' iA . , " " f ",,~ it .~J :"1\' 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 '-- ') ~ Owner I'" ~,..,' ~........,ck,r I 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 ,--- (:) uJ tVf-Vi-. _,\\0 Phorp ~e'" r0\~\'"~ ~ eo..'\}\ (l,0~ :1.\0 Cit" ,.oJ ~ ~~Statp Coe ^f\' . o{\ \V X\e ~ '3-' ~ 1ijt:- \. . , ,,0\eg 0'0'1" ~'\}\0'" \>o~g \}\0'" Construction Contractors Reglstrabon,jf,\e __n",e ^'(\ 0 . .Y\e ~. ^~e "" ~ \ ,-. "",-o'v',., "<<-.fOVJ.. 0' . H"O" "~O" ~ \ ~ ~\}\"'- (je{\':OO\\) ,. (,o'V\~'\X\e \.""O\\~\f:,v \O\\~ (,'3-\\o{\",OO\ o'O\'3-\{\\~o\e\\~\\'I ~o.t>.'" 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~\'" '\ "~~e' ~". ~'\}~ _ (je ~rurp.~ Signatun''- 0.o~~ 'l~~ ,,!,\Q.~~\~Jt~~S~~-Z ~ - 03 - ~ - \:,1'" \:.{'''''' Q\'I. ~\)~~~~~;'n ~:~~~ ~~~~~ru~~\) ~ lr'i~ ~It'i.. ru\'l. \~ F'-\{,~,~<",,~@ <:>(.9,,\'\j\). . ru~\"~ \w-\ \ ' ~~i)\'O~ . o '0 2'7 c:; Addrers Zip Expires Date of Application Checked for Delinquencip< ~ Checked for Historical Status ~ Shared Drive (T:)/Building FonnslBacknow Preventionl-03.doc " , ',\, " ., , " - ), ''''' . ..., .. . . . .11 f'\ \ i .,. '-f ". \ ' ,. " " ,. . " " ; ^ , . " , \ \ '/ , \ \ i , I \ \ \ \ - - i~ '- I / WI' ;::..- .-'--------- ~ . . I). . . . . \" ,/ " " . .' . . 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 . .