HomeMy WebLinkAboutPermit Mechanical 1990-9-26
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Flfth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
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Assessors Map jj: \hO~fl\ 0 \ ~
Owner: \=:)\ 0 ~ t\(\ N\J))(
Address: '2l')4 \ Q 01\0 J\ r\ '( \LQ Dr
City: 8~\:J rl-- __ -., State: JOXL 06
Value of Vood \Jove/~r;t 'Stov~lInsert: ~ ()I~
(please circle appropriate appliance) "(
Tax Lot
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Phone
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Zip: Cfl4lh
prelimlnary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspectlon Requested: Q g, ~~ Q tJ b\lTI ~
contractor:\UxA ~\~ () ~ DC' tJJ '(\J\&L
Address:, 4~ffi [.. H\ri'0C\ r~f\j at Phone jj: ~[ol\ -&")\'1
City ,~t"\Q QX ~\\\y\Q State: l~ ~ o (i(JV\ Zip: G, (~<K to
Construction Contractors Registration jj: l 0 ~ t;:.,C)'ZS EXPires:.J.l--ll3..jQD
By slgnlng this permit/appllcation, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was provlded with the Vood Stove Safety information for wood burning
appllances and prelimlnary inspectlon standards. I also understand that if I am
requesting a preliminary lnspection, the wall covering may be required to be removed.
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01gnature. -"'"/-
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/~~NSERT
Date of Application: C(-8to - Job
To tal Amoun t Collec ted: c<J (0 8 ~
Receipt jj' ~~~
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Issued By:
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Checked for Delinquencies'
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Checked for Historical Status'
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Issued by?1! m ) Date 9/A-0/10
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 bUlldmg permIt can be Issued Licensed Architect
and Engineer applicants, exempt from registration under ORS 701 010(7}, need
not submit this statement This statement will be filed with the permit
Fill In the applicable blanks, and Initial box 1 and either box 2A or 2B
1 ~ I own, reside In, or Will reside In the completed structure
2 A ~ general contractor IS ~~ N\.DO-+;(\r'~ StJY7 )(QO
Contractor registration number L() A..tf--O~
I Will Instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board
OR
B L-J 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 ao hire a Qeneral
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 certrfy that the above rnformatron 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
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IgnalUreof Per'rnlt~Applfcant--
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Date
CONSTRUCTION CONTRACTORS BOARD
0244J 10/24/89
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Wi:lJ]'E COPY TO ISSUING AGENCY PERMIT FILE
/' . \M~' COpy TO APPLICANT
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