HomeMy WebLinkAboutPermit Mechanical 1990-10-4
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
. Office:
INSPECTION LINE:
726-3759
726-3769
Job Location:
;2) L/:] LA u~A
!I: 17n:3:J '7 10
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Assessors Hap
Owner: ~~O ff
Tax Lot !I: (') / ')(00
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Address: ~ / </3 LAul'Z A
City: .:3'i:>FL /) , State: 012-
Value of ~ood Stove/Pellet Stove/Insert~ I.~ Cj g .
(please circle appropriate appliance) ,
Phone !I: "J L/ / - ;} c.; 0 d......
Zip: q 7'-/ 77
00
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 +..... state surcharge + $10.00 Issuance
$1,].5
Type of Inspection Requested: //1/SE /2... /' PE/Zmll
Contractor: (!. 1/2... C 1_ ~
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S C'O/l/,<:;Tt?..lJ~ II DAJ
Phone !I: 3 vcr -s S 8",;(
Address:
City: rv({, r-::N~ State: O/Z..r;:-
Construction Contractors Registration !I: ~~~I 0 \
Zip:
Expires: q JG\ let I
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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
appli ces and preliminary inspection standards. I also understand that if I am
reque ting a preliminary inspection, the wall covering may be required to be removed.
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Date
/Si~a'ture -
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PE~T<fN~=)~' PRELIMINARY
Date of Application: If') ,..4-Cfu Job !I: qt\\~'{)~
Total Amount COllect~drl)l 0 . 'rl-S I" fJ ~ ;
Receipt !I: /~4-3 Issued By: ~ f LA J.. .J
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Checked for Delinquencies:
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Checked for Historical Status:
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Permit No: . q()/fY){J. _.)
Addrn"'11!iJif~ jj//LJ
Issued b .' ,) Date: If) .4.Q() ,
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..L=l
2. A. WLJ'
I own, reside in, or will reside in the completed structure.
My general contractor is 0\\(\ \0 l\ 0m~ )\\\\_'l\ bOT\
Contractor registration number 4g '8/0 { .
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 Clo 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 InforlYi8ti(ln Notice to Property Owners about Construction Responsibilities on the
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, CONSTRUCTION CONTRACTORS BOARD
0244J 10/24189
~ COPY TO ISSUING 'AGENCY PERMIT FILE
COPY TO APPLICANT
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