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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:' tfkl &:lJ1vru Assessors Map #: \" D3 ~ 3 ::\4 12. ()', \ff7/1/71-A/l Address: 1JL,,1 f67fM11 f /-6-M- ..01d Tax Lot #: '- (')q \ ro Owner: City: State: '7 Lj 7 - ;;J{f) I G 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. <<a~~ Sig'nature ~.h071 d 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.. ", ~~ '" ~ '\/ '~,' . 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 I/ho~f () Date I . CONSTRUCTION CONTRACTORS BOARD 0244J 10/24/89 " ~~G ,,", U(~I:r-E COpy TO ISSUING AGENCY PERMIT FILE ~PIbI~COPY TO APPLICANT U'.A- , . ./~ @Is .;~