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HomeMy WebLinkAboutPermit Mechanical 1990-1-2 , ." ,~/ " .. " . , . . ........ .., SPRINGFIELD , ., WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: L\-C\6C\ \:J(\~U ~:Xe~ Assessors Map #: y,\ Dd~3~? \J Owner:, \\ ffi)\C\ > _ ~~ '\JI V ~ ~~\(\ ~\~\ \ st" o ~ (\) Qte: Tax Lot #:j)\f\?~~ Phone #: ~\0-4ry),o. _ Zip: C\l118 ~: ,c. "'/, Stove! s t: ~ c', "T'C" e appropriate appliance) r1 r~\-rf' Preliminary Inspection is $15.00 (prior to installation of insert) Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge Type of Inspec~ion Requested:\ l~.,~l~ <1 ~ \~ Contractor: ~Ch Q~ Address: -' Phone #: - City: '---' State: Zip: Construction Contractors Registration #: ,-- Expires: .. By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I also state that all information on this application/ permit is correct and that I was provided with the Wood Stove Safety information . for woo:zrning appliances and preliminary inspection standards. J~~fu'r.e ? 1<- /)1e-~rr &;;1- 9.0 I' FOR OFF ICE USE REQUIRED INSPECTION(S): ~OD srn~~INSERT (-2 on ~{,7-l~' ( P \ Date of Application: . -\ "" Job #: c:::- :';', I\. ~.t::-~" Receipt #: J ~ (0 '1~ Issued ~y.., LD~J Checked for Delinquencies: ~ Checked for Historical Status: ~ - PRELIMINARY rC " " ~ ." '" . . "'- ' Permit No: m 1m I - . Address:4qC\~ \X\ t D\)<_ . ,Issued by: ~8rfi, ~ate:Li~O '. " . 'STATEMENT: INFORMATION NOTICE.TO PROPERTY OWNERS ABOUT. CONSTRUCTION RESPONSIBILITIES. Note: dregon Law, ORS701.055(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.Arc'hitect . and Engineer applicants, exempt from registration underORS 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.......-{ I own, reside in, or will reside in the completed structure. My general contractor is , 0.. , 2. A. I Contractor' registration number I will instruct my general contractor thatalls.ubcontractors who work on the structure must be registered with the Construction Contr~ctors Board. OR B. L!/ l 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 00 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 certify thatthe 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. . ,*/L.~ /A ~'1 e ~ Signature of PermifApplican, 1-'-]- 7tJ Date "'. . ' , . CONSTRUCTION CONTRACTORS'BOARD '. ., 0244J 10/24/89 ' ,.;. . . } . ,_.... . ,'WHITE .COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT. ":, ~s ,"