HomeMy WebLinkAboutPermit Signage 1990-1-2
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WOOD STOVE/INSERT INSPECTION APPLICATIDN
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
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726-375~~
726-376~ ~
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Assessors Map II: \'1 T1 ~Qf(\ \ Q
jtetftU/ i.e.jc},e/t--
Address: /q5Z-/ ~11d. ;1v~.
City: -61jd.. ' State: OIL
Value of Wood Stov~ l3D() ,0 D
(please circle approprlate appllanceJ
Job Location:
Tax
Lot II: rYJ:i('y)
Owner:
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Phone II:
7'?-Lt ;qt.aI..eD
Zip: fl1'-/71
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: rf/u---u...S1z.tt)7(5V\ f J-(Iyurl-
Contractor: t:rarl- [~
Address: '/R i) ~, ~ 1"). l O~ Phone II: 4R ~ -D 5"0 Q
City: Y..\ )a~ State: I J:)){U Zip:
Construction co~ractors Registration II: 4/ i t:}()r;- EXPires:JD)Z15/!1D
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
fO:7Z~R~~spection sta~;:. c)/ /9;10
~lgnatuFe ' Uate
FOR OFF ICE USE
REQUIRED INSPECTION (S): WOOD STovEFE'ir~.. ") V PRELIMINARY'
Date of Application: \ - f'\ -0:.( ) Job II: ,c:..J::7" ~
Total Amount Collected: <.....6JJ .'t1 S . t:..~~~
Receipt II: \ ~wf')L() Issued By: YK\ m )
Checked for Delinquencies: Y\, \~ Checked for Historical Status: l~
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Permit No: RS!3 X ~ , ,q!
Address: I q~om on ] _
Issued by:C!rI-,fj] ~'. Date: lr!J-q{)
STATEMENT: "
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUqlON 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. ~, I own, reside in, or will reside in the completed structure.
2. A. r::izf My general contractor is' ('194FT S 7V Vr.;;-
/ Contractor registration number r.j &> 5"Os-.
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 subcontractcirs~1 will hire only subcontractors registered with the
Construction Contractors Board. If I change my mind and aD 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 90ntractor.
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 ~hiS form. it
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'-Signah:i~iSermit App icanl ' Date,
CONSTRUCTION CONTRACTORS BOARD
0244J 10124189 . , ' ,
WHITE COpy TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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