Fill and Sign the State Construction Registry Dopl Utahgov Form

Preliminary Notice - Utah State Construction Registry 30 E. Broadway Suite 300 Salt Lake City, UT 84111 (801) 983-0275 or (877) 9UT-EGOV FAX: (800) 585-1534 SCR User Name or Account #       This Preliminary Notice is fled for State Construction Registry Project #: Note: A valid SCR Project #, Building Permit #, or Project ID # is required      Project Information Building Permit # or Project ID: Building Permit/Project ID Not Applicable Issuing Municipality: Not Applicable Original 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 Person(s) or Entity that contracted with the claimant for furnishing the labor, service, equipment or material:            Name of Record or Reputed Owner of Project:       General Description of the work, service, equipment or materials to be supplied:       Filer Filer Type: Subcontractor Supplier Filer Name and Address:                   Same as listed under SCR Account ID Specifed Above Filer Telephone:       Fax:       Email:       Notification I prefer not to receive notices concerning this fling. List the email address, postal address, or fax number of up to three persons to receive notifcations concerning this project: Email Notifcation (No Charge) Email 1:       Email 2:       Email 3:       Address/Fax Notifcation ($6.00 processing fee per address) Address/Fax ($6.00)       Address/Fax ($6.00)       Address/Fax ($6.00)       Payment Processing Fee __ Notifcation 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 fle 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 are associated with the State Construction. Fees are non-refundable. Filings will be deemed “fledd when the designated agent receives a complete form and valid payment. Incomplete flings will be returned as not fled and corrections will be subject to an additional processing fee. The individual or entity fling this form assumes all liability for the completeness and accuracy of the form, and for it being “fledd within the time limits specifed 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 specifcally disclaim any liability for the timeliness and accuracy of any flings, including alternate flings submitted according to ofine methods (for example, but not limited to, telefax and mail submissions). Signature: Title: Date: