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Preliminary Notice - Utah State Construction Registry30 E. Broadway Suite 300Salt Lake City, UT 84111(801) 983-0275 or (877) 9UT-EGOVFAX: (800) 585-1534 SCR User Name or Account # This Preliminary Notice is filed for State Construction Registry Project #:Note: A valid SCR Project #, Building Permit #, or Project ID # is required Building Permit # or Project ID: Building Permit/Project ID Not ApplicableIssuing Municipality: Not ApplicableOriginal Contractor Name/DBA Name: Name of Person or Entity Furnishing Service: Original Contractor Telephone: Telephone of Person or Entity Furnishing Service: Project Address: Address of Person or Entity Furnishing Service: Project Type: Commercial Residential Name of Record or Reputed Owner of Project: Name of Person(s) or Entity that contracted with the claimant for furnishing the labor, service, equipment or material: Project Information General Description of the work, service, equipment or materials to be supplied: Filer Type: Subcontractor SupplierFiler Telephone: Fax: Filer Filer Name and Address: Same as listed under SCR Account ID Specified AboveEmail: I prefer not to receive notices concerning this filing.List the email address, postal address, or fax number of up to three persons to receive notifications concerning this project: Email Notification (No Charge) Email 1: Email 2: Email 3: NotificationAddress/Fax Notification ($6.00 processing fee per address)Address/Fax ($6.00) Address/Fax ($6.00) Address/Fax ($6.00) Payment Processing Fee __ Notification Addresses X $6.00 Total Fees: $6.00 + Check Enclosed – Check # (make checks payable to Utah Interactive) Bill my Visa Mastercard Card # Expiration Date: / I have an account on file with the SCR – please bill me. NOTE: If you do not have a credit account with the State Construction Registry program, you must include payment of check or credit card. Failure to provide payment will result in this notice being returned as not filed.Terms and Conditions – Processing fees are due at the time of filing. All fees associated with the State Construction Registry are posted at the SCR web site: http://scr.utah.gov. Fees are non-refundable. Filings will be deemed “filed” when the designated agent receives a complete form and valid payment. Incomplete filings will be returned as not filed and corrections will be subject to an additional processing fee. The individual or entity filing this form assumes all liability for the completeness and accuracy of the form, and for it being “filed” within the time limits specified in Utah state law. Neither the state of Utah, the SCR, nor its designated agent is responsible for lost, late, or misdirected mail. The state of Utah, the SCR, and its designated agent specifically disclaim any liability for the timeliness and accuracy of any filings, including alternate filings submitted according to offline methods (for example, but not limited to, telefax and mail submissions). Complete terms and conditions are available at http://scr.utah.gov.Signature:Title: Date: