HomeMy WebLinkAboutPermit Mechanical 1994-10-17
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: \f'f\ \ ~M) }
Assessors Map #: I~M li 0 r?J .
Owner: \\'t\ \\. \,\ \ tX"\ ~\ n t 1\0
Address: \D'\ \ l\ \ ),'f\~ _ Phone: #:
City~\H\ .' State: \ l~~~ Z~ Code:
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Value of bood Sto e Stove/Insert: I .
Tax Lot #:
/13DO
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Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total - fl \ \ -1 ~
Type of Inspection Requested: ~ \0 1\ ~ m -\ V, LU1L ~f\<Xf+
Contractor: ~)\l\.\t lt1l\.~ .
Address: \ RV\S \)1I '). l~ Phone It: M-.. S. DS~ ~
City: ~6-y'~ - State:\ ~~H6)aY\- Zip Code: -Qr\fl7- -
construc::o: C~tractors Registration .#:~ Expires: \.\J :1A.Qi
By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided with the Yood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
may be required to be removed.
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FOR OFFICE USE
Checked for Deliquencies:_
L----- PRELIMINARY, V
Job #: ~\7JC\It.
Issued BY:~_~
for Historical Status:
REQUIRED INSPECTION(S): YOODSTOV~IN~
Date of Application: 1 D . /I).tr=t
4\,11) .
Total Amount Collected:
Receipt #: \"VJ\t1)
Checked
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Permit#: ~2-
Address: I tn I \)\{\ 1f'L..
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Issued by: ~(~ Date:
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Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. 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 appropriate blanks and initial boxes I and 2, and either box 3A or 3B:
1. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
Kf'A. My general contractor is J' _ID f{-l Sf1 'R.~ 1- (05- .ad
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
D 3B. 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 hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
1Y!,f',/)A!!-!. r /U~ 11-1/7 / J l/f'
. . . fignature ofpe~t applicant) - -(Date) / I
(White copy to issuing agency permit file,
pink copy to applicant)
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][nformation 'Notice to Property Owners
Abou~ Co~struction R~sponsibilities
Note: Thi~ Information Notice to Property ()wnerf about Construction Responsibilities
was developed by the Construction Colltractors Board in accordance with ORS 701.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent many problems by being aware of the following responsibilities and areas of concem.'
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors .Board to do labor in constructing or assisting in the
construction or improvement'of a residential structure, y.ou will, in most instances, be ruleq to be an employer and the people
you hire will be employees, As the employer, you must comply with the following:
Oregon's withholding tax law: As an employer. you must withhold income taxes from employee wages at the time employees
are paid, You will be liable for the tax payments even if you don't actually withhold the tax from your employees, For more
information, call the Oregon Dept. of Revenue at 945-8091.
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Division at the Department of Human Resources
at 378-3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job, For more information,
call the Workers' Compensation Division at the Department of Consumer and Business Services at 945-7888,
u.s. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable for the tax payment even if you didn't actually withhold the tax, For more information, call the Internal Revenue SerVice
at ] -800-829-1 040.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the permit holder for this project. you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections,
Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
re-done,
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough-in and finish
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309-5052,
503/378-4621), The Board is located at 700 Summer St. NE Suite 300, in'Salem. '
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