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HomeMy WebLinkAboutPermit Signage 1990-1-2 :.a~.,'..' . WOOD STOVE/INSERT INSPECTION APPLICATIDN CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: I;' 726-375~~ 726-376~ ~ I q 5W L--o fY'llJll\ cL A- v' -L , 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: ~{cJt 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~ ./, .--i,. . . 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: ~ji 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 x4~ &: ,/~~ JIJ~. d /9JD '-Signah:i~iSermit App icanl ' Date, CONSTRUCTION CONTRACTORS BOARD 0244J 10124189 . , ' , WHITE COpy TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT .~~ ,~ ~,