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Home My WebLink AboutPermit Backflow Test 2004-11-29 ~~;--.. . . CITY OF SPRINGFIELD Building/Combination Permit PERMIT NO: COM2004-0I452 ISSUED: 11/29/2004 APPLIED: 11/29/2004 EXPIRES: OS/29/2005 VALUE: Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769 Inspection Line SITE ADDRESS: 6068 PUMICE PL ASSESSOR'S PARCEL NO.: 1802033400117 TYPE OF WORK: Backflow Device TYPE OF USE: New Residential PROJECT DESCRIPTION: Backflow device Owner: WARD CHRISTMAN Address: 6068 PUMICE PL SPRINGFIELD OR 97478 Phone Number: 541-988-1814 Contractor Type Plumbing , CONTRACTOR INFORMATION' NOTICt. F TH!: WORK ContractoGHIS PERMIT SHAll EXPIRE I 'I.:Jte.ns~lT OWNER AIITHORIZED UNDER THIS ~~R.~"~nl~ COMMFoCRnfN'Gm'ffiRM;\T{oN ~I" '{ 18 "'1 1"" AN u un ,~'''~_. # of Stories: Height of Structure Type of Heat: Water Type: Range Type: Energy Path: Sprinkled Building: Expiration Date Phone # of Units: Primary Occupancy Group: Secondary Occupancy Group: Primary Construction Type Secondary Construction Type: # of Bedrooms: VN Lot Size: Sq Ft 1st Floor: Sq Ft 2nd Floor: Sq Ft Basement: Sq Ft Garage/Carport Sq Ft Other: Occupant Load: R-3 nla I DEVELOPMENTINFORMATION , REQUIRED PARKING Front yard Setback: Side I Setback: Side 2 Setback: Rearyard Setback: Solar Setbacks: Overlay Dist: # Street Trees Rqd: Paved Drive Rqd: % of Lot Coverage: I 'J~~~1:2l ATTENiION; ?~~b~~oro~~~ I PUBLIH~R~<~S~~oAAii2-4!l)~" '''-0' .0 g52..()OlOUU ,l. '''ll<Gi&hD'plIi;P'lrl1 In "" btaln COp'" ;;,~'\iii1O 0090, You may 0 lMotl>>sn.'ri~~~~w. s' calling \he center. y~ UtI\lty~8a~ ' nU(l\bertoIUleO~n~~ centet!a .-- Total: Handicapped: Compact: Street Improvements: Storm Sewer Available: Special Instruction: Notes: I Valuation Descrintion I Description Tvpe of Construction $ Per Sq Ft or multiplier Square Footage or Bid Amount Value Date Calculated Total Value of Project Pal!elofZ . . CITY OF ~1"Kl1~uFIELD Building/Combination Permit PERMIT NO: COM2004-0I452 ISSUED: 11/2912004 APPLIED: 11/29/2004 EXPIRES: OS/29/2005 VALUE: Status Issued 225 Fifth Street, Springfield, OR 541-726-3753 Phone 541-726-3676 Fax 541-726-3769Inspeclion Line I F~es tiWU Fee Description + 10% Administrative Fee + 7% State Surcharge Backfiow Device Minimum/Adjustment Plumbing Amount Paid Date Paid $4.50 $3,15 $14.00 $31.00 11/29/04 11/29/04 11/29/04 11/29/04 Receipt Number 1200400000000001656 1200400000000001656 1200400000000001656 1200400000000001656 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. I Renuired TnSfection\J Backfiow 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 this project. I further agree to ensu that all required inspections are requested at the proper time, that each address Is readable from the street, that the per ' car is located at the front of the property, and the approved set of plans will remain on the site at all t21 zu. co uctlon f (/2.-'1 foe-( Date Paee 2 of2 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number COM2004-0 1452 COM2004-0 1452 COM2004-01452 COM2004-0 1452 Payments: Type of Payment Check 11/29/2004 . RECEIPT #: 8,~"NQI'1~ ..~ !, ilk' -. ; .JiIi!y of Springfield Official Receipt .elopment Services Department Public Works Department 1200400000000001656 Description + 7% State Surcharge + 10% Administrative Fee Backflow Device Minimum! Adjustment Plumbing Paid By WARD CHRISTMAN Received By djb Page 1 of 1 Date: 11/29/2004 Item Total: Check Number Authorization Batch Number Numher How Received 1030 In Person Payment Total: 8:38:09AM Amount Due 3,15 4,50 14,00 31.00 $52,65 Amount Paid $52,65 $52.65 e, . , \, l " " " " . .' . '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 #: COM z.oo'- 0 Il..{ s" z... Issued by: bob g- DCS P,^",^I~ I~L.. Date: 11/2-7/0'-1 . I 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 al",uvl"riate blanks and initial boxes 1 and 2, and either box 3A or 3B: ~l. cr2, 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) CCCB #) 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 t ve information is correct and that I have read and do understand the Information ners about Construction Responsibilities on the reverse side of this form. ~ (f/vt/Oc./ 7;l'~ v ~ (Signature of permit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant.) Property_owner,doc 06-01-04 , :. . Adnll1l~ ~~ ''l1 ((J)U1llT' <<J)Wll1l CGtell1llelT'~n CC((J)ll1l~lT'~~~((J)lT'? INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES . NOTE: This Information Notice to Property Owners about Construction Responsibilities was developed by the Construction pontractors 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, lEmjplllcyeJr Re~jplclID.~i1blilli~ie~ 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 employecs 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 Business Identification Number (BIN) is a combined number for both Oregon Withholding and Unemployment Insurance Tax, To file for a BlN, call 503-945-8091 or www.dor.state.or.us/formsnav.htmll for the a...p"u....~ate fonns, 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 infoi;mation, call the Workers' Compensation Division at the Department of Consumer and Business Scrvices at 503-947,7815, U,S. InternallR.evenue 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 ElN number, call the IRS at 1-800-829-4933 or visit their web site at www.irs,l!ov, <(])~lh1eJl" lRe!lj]}oIill!lfiJ]}finfitie!l ~ml!Jl AJl"e21!l Oll COIilll!:errIill!l Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requiremcnts that may be brought to your attention through inspections. I', ,Liability and lI'roperty Damage Insurance: Contact your insurance agent to see if you have adequate insurance coverage for accide/lts and omissions such as falIing tools, paint over spray, water damage from pipe punctures, fire or " work that must be re'dorte, ! , Time: Make sure you have sufficient time to supervise your employees. IExpertise: Make s:J.re you have the skills to act as your own general contractor, to coordinate the worle 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 additiol1lll questions call the Construction Contractors Board (503-378-4621) or write the agency at PO Box 14140, Salem, OR 97309-5052. Property _ owner.doc 05-01-04 " 220 rWrH STRt:t:r . SrRINGFlELD, OR 97477 . 1'1'1:(04 J)72G-3703 . rAX: (04 J)72G-3Gl\9 ~. 0: ._~ ~; ro ,) U: Assessors Mar .,I'!'""l ~: Owner /Ahn~ ()a/i~fvwtt V\ ~:11 Addre~o IpDfl9:; ~""~ D/. ~' City S,t?Yl'AU.t;PUi. '@. C;)) ~~ (1); u) Contractor .,~j ~, Addrt>ss .<1); n\ City ~; C)J ." ,...-.l~ ~) ~j 0)) ?/ 0)) ~~ ~~ >-" ~ e) ~~ Date of Applicatior ~: t)) a\$: ~l , . . City Job Numbe,Q:?'V> 2.001../- O(L/ '5 2..... Job Location (,7nt#J 1Pu.L>t; u... ?f. I fOZ 0331.{ Tax Lot 00117 Phorp ?jfjg -/'l3/4 Statp 0 R... Zir C!7L{79, BACKFLOW PERMIT IS $52.65 (includes Permit Fee, State Surcharge & Administrative Fee) NOTICE: COli tractor IlIformatioll THIS PERMIT SHALL EXPIRE IF THE WORK ~ AUTHORIZED UNDER THIS PIBMf(IS NOT t")W Nc-fLCOMMENCED OR 1S-A&A1\11ln~lm enD MIH Ill~IOD, " ~ Phonp ~ ~ Construction Contractors Registration # Stat" 7,ip Expires By signing this pennitlapplication, I agree to call for an inspection once the backtlow prevention devise has been installed and is visible for inspection (726-3769), I also state that all infonnation on this pennitlapPl~'cafjfOiS~C / ATTENTION: Oregon law requires you tp Signaturt" III I;,ttt A?=':. ,rull?WrUle~ adopteo oy th~IWOnjlit.ilrlZ-'7' /0<:.( t/ V - r.\'"f'ua"ull "''"'Ilt:I. I nose-ruYe'S are set forth' -- in OAR 952-001-0010 through OAR 952-001- 0090. You may obtain cooies of thl> ro .".., hv For 2m~~ :e~n~~~ ~~~t~:.~~e tel~pho~e - - ---= -.:'03..... \::'\:""1 ~\'\lfll.'QUVI' / V Center is 1-aOO-332-2344). / ! Z 7 CJ L( , V-- ' Checked for Delinquencit"o Checked for Historical Status ~ Shared Drive (T:I'Building FonnslBackflow Prcvcnlionl.03.doc