HomeMy WebLinkAboutPermit Plumbing 1990-4-25
BACKFLOW PREVENTION DEVICE PERMIT APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-.3769
Job Location:'
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Assessors Map #: \" D3 ~ 3 ::\4
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Address: 1JL,,1 f67fM11 f /-6-M-
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Tax Lot #:
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Owner:
City:
State:
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Zip: q7iJ77
Backflow Permit is $15.00 + $0.75 State Surcharge
Contractor: !J7~~~
Address: Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
~ signing this permit/appl;cation~ I agree to call for an inspecti6n once the
backflow prevention device has been installed and is visible for inspection
(726-3769). I also state that all information on this application/permit is
correct.
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Sig'nature
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Date '
FOR OFFICE USE
Date of AppliCation: 4-. Q S.qO L Job #: G('nc}(0/)
Receipt #:' lC'??r1~ Issued BY:,~ \\j"~ _) ,
Total Amount Conected: \~.f\S.. ", ~~
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Permit No: ' qyy\ 01 ,
Address:, 4\ Q \-_\~\l\ ttS\)llL ,
Issued~y: 'fA\\'iLU Date: -4 !~cyqO
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law,ORS 701.055(4), requires residential building permit applicants
who are not registered with the Construction Contractors Board to sign the,
following statement before the building permit can be issued. Licensed Architect'
and Engineer applicants,exer;npt from registration under ORS 701.010(7), need
not submit this statement. This statementvitill be filed with the permit.
Fill in the applic?ble blanks, and initial,box1and either box2A or 2,B:
, /'
1 ;,1 V '1 I own, reside in, or will reside in the' completed structure.
2. A. ,I My general contractor is
Contractor registration number
I will instruct my general contractor ,-that all subcontractors who work on
,the structure must be registered with the Construction Contractors Board.
OR
B. 1 1/'1 I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the
Construction Contractors Board. If I change my mind and co hire a ~eneral
contractor, I will contract with a contractor who is registered With the
Construction Contractors Board and I 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 understand
the Information Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
/::PiJ~0#~.
'<Slghalureof Permit Applicant
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Date I
. CONSTRUCTION CONTRACTORS BOARD
0244J 10/24/89 "
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U(~I:r-E COpy TO ISSUING AGENCY PERMIT FILE
~PIbI~COPY TO APPLICANT
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