HomeMy WebLinkAboutPermit Mechanical 1990-2-5
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
35 ~ q P/1n/U-./Y\J
Assessors Map #: \ 1\ (') 9.'2fY\'2\ (
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Address: ,,3<;, r-J. q ~
City: ~~ 01,1 State:
Value of ~Insert: ~<jOIJ. tJV
(pl~~U~t~~approprlate appr~ance)
Job Locat i on:
Tax Lot #:
()()v(Y)
Owner:
Phone #:
?de:, -577"9
Zip: '17V77
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: ~~~ ~~\)~
Contractor: ~~
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 wood burning appliances and preliminary inspection standards.
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FOR OFFICE USE
REQUIRED INSPECTION(S): WOOD STOVE INSE~T
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Total Amount Collected: \ S ,'l~
Receipt #: : \~'\O___....,.. Issued By: "-d\t ~
./ PRELIMINARY ,,_ /
Job #: q(y)1 (00
Date of Application:
Checked for :Del inquencies:
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Checked for Historical Status: ~
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Permit No: Cf (1))(0 ~
Add"" ?,~ GJ, \0--\-\\ ~ ~ 0
Issued by; ;{(~.-J Date: {) ,S,g
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:
1. L-..J
I own, reside in, or will reside in the completed structure.
2. A. L-]My ,general contractor is
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
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B, LfLJ 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 Clo 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 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.
dAMU- ~71 Jf::~
~ture Of Permit Applicant
!J~- FE;J- 90
, Date
CONSTRUCTION CONTRACTORS BOARD
0244J 10/24/89'
'11': ::-:-: SCf'Y TO ISSUING AGENCY PERMIT. FILE
;.';; f!ltm eopv TO APPLICANT
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