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Permit. No: - ,, ._
<br />Address: ~")}q~,::"~)dtO'Vy'th'y ~.
<br /> q
<br /> by: ...... : 'I.~
<br />Issued ~ Date:' ,~.~
<br />
<br /> STATEMENT:
<br />INFORMATION:, NOTICE'TO~ PROPERTY OWNERS
<br />ABOUT CONSTRUCT:ION ,RESPONSIBILITIES
<br />
<br />Note: Oregon Law ORS 701.~55(4),.reqU res res dent[a ,bud ng ~permlt applicants
<br />· .who are not ·registered with~.the.Construction'. Contractor~ Board, to sign' the
<br />tOIIowing state,neat before the bu ding. permit can be,issued;' Lider{sed Architect
<br />and Engib~r"a~pplicants exemp't' fror~.re.g,istrati0n..u, nder'OF{S 701 0,'10{7) need
<br />not, submit this' statement. Th s sta.tement will ,be hied with the ,permit.
<br />
<br />Fill in the app cab eb anks and initial, box I and either box 2A or 2B:
<br />
<br />1. f--~_._ I owns,. ',~, de¢. ,~., ' ~'''-'in' or will
<br /> reside, in' the, Comp eted
<br /> structure.
<br />
<br /> .Contractor regist Cation~:nu m ber '- ,.~
<br /> I will instruct my, genera.I, 'contractor that all subcontractors who work on
<br /> the structure must be.registered with the Construc~ bn':'Contractors Board
<br />
<br />OR
<br />
<br /> · ~., ':~ . ;,,'
<br />I will be my own general contractor. , ,r ~:.
<br />
<br /> h,re subco;.ntractors';,.I.w~'lt~hlre only subcontractors r~g:r§tei~ed with the
<br /> ~;OnStruction uontracto:r~ ,,.Bqa','rd,~ 'f I change.my m nd, and do hirea Qeneral
<br /> c~ontr.acto, r.,, I w~ill .COn.tra'c,t,~th',;a contractor who,-,is regist.e, red w~th the
<br /> .~on.s~ru.c,t.!on. ~,o,n,~ractPrs,',¥oa~r~ ,and .w "mined ately nohfy the office
<br /> ~ssumg.~nls Dui~o'ing peFm~t ot the name of, the contractor.,
<br />
<br />I hereby cert!fy~ha..t the aboT~nf~.~. ~on is correct and that I have read a.n.d, understand
<br />the Informat,b...n~. flce to P~erpe~,~OWn'ers about Construction Responsibilities on the
<br />reverse side of th,s form. , ":, :' . .....
<br />
<br /> Sig~
<br />
<br />CONSTRUCTION CONTRACTORS BOARD~ ';"..'
<br />0244J I
<br />
<br />FILE
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