HomeMy WebLinkAboutPermit Mechanical 1991-2-28
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Offi~e: 726~3759
INSPECTION ,LINE: . 726-3769
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Job Location:
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Assessors Map II: I/D~ 1'500
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City: ~V"\ \l'\Zr~; P '..a: State: 00
Value of Vood Stove.nsellet Sto~/Insert: D1..:uJn ad
(please circle ~all.~'-appliance) .
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Tax Lot II:
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Owner: .
Address:
Phone II: ,"'4 'j4/ .:. ~"70
Zip:
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, Pr,eliminary Inml,ection is $15.00' (prior to installation of ,insert)
Vood Stove~Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
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, Type of Inspection Requested:
Con t rac tor:
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Address:
Phone II:
City:
State:
Zip:
Construction'Contractors Registration 1I:
Expires:
By signing this permit/application, 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 provided with the Vood'Stove Safety information for wood burning
appliances and preliminary inspection standards. I also understand that if I am
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signlt':r. t! / / / /, ,- < Da te '
1/ 1/ FOR, OFFICE USE
REQUIRED INSPECTION(S): VOODSTOV~E~INSERT ~ PRELIMINARY
Date of Application: ::Lb.<,( \" I ' ' Job II: a I') /4S q.
Total Amount Collected: ~ {"". ::4, ,
Receipt li: 1 '16 II'
Issued By:
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Checked for Delinquencies:
Checked for lIistorical Status:
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Permit No: OJ 01 Lrs; 0;
Address:. fc,~ I Cr;tftvlA cJ! Q v
Issued by' I.) f<, Date: 2bx Iq I
FOR OFFICE USE ONLY
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 building 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:
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1.~/
2.A.L...J
. My genera.1 contractor is
I own, reside in,. or will reside in the completed structure..
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Contractor registration number
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 general
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.
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I hereby certify that the 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.
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Sigl1titu(e;-b'f P~rrn1t Applicant
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CONSTRUCTION CONTRACTORS BOARD
0244J 1/90
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'Date' v (
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WHI+6 COPY TO ISSUING AGENCY PERMIT FILE
f'INI( COPY TO APPLICANT
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