HomeMy WebLinkAboutPermit Mechanical 1994-11-28
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION .
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: \.OR~ ~(\ e.IDCf-
Assessors Map #: \ ~Mr\o\ 4 '0
Owner: \<~\ ~ \ \~.) \)\ r--ll' ,0---
'dd'~~"'~'Yt 0 Pt
. City. If\ qtate:
Value of ood Stove/~
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total \\ .
Type of Inspection ReqUer~d~\O \ i N\~ I )(.0\ ~1) U\~
contractor~~\C\\J-' ~~\O[\) .
Address:\.~JK\~ -c04G\'\(\ ^' Phone #: lo~~ .3Q\()
City: ~n9J\9--. State:\)jj~ Zip Code: Of\L\{)2-
const~uction ~ntractors Registration #:~~ Expires: \\): 9.~.Cl.~
Tax Lot #:
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Phone: #:~-f)2.~~' .
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By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided with the Vood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that \t'f I am requesting a preliminary inspection, the wall covering
may be required to be roved.
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~i~re Date
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OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE PELLET/I~
Date of Application: I f.PA.q.
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L--' PRELIMINARY
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JDb #:
Checked for Deliquencies:
Issued BY:~'~
Checked for HistDrical status:
Total Amount Collected.
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Receipt #:
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Permit #:
J
Address:
Issued by:
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. 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 appropriate blanks and initial boxes I and 2, and either box 3A or 3B:
I. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
P 3A. My general contractor is ~-k..~ 1-125ll.5
(Name) Contractor regis. #
I will instruct my general contracto at all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
D 3B. 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 hire a general contractor, I will contract with a contractor who is
registered with the CCB and 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 do understand the Information
Notice~roperty Owners about~truction Responsibilities on the reverse side of this form.
IL~",,,, ~. . \)\:\ 0'1.1... IH \\ -~~-q,-t
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(Signature of permit applicant) (Date)
(White copy to issuing agency permit file,
pink copy to applicant)
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. ][niormatlon'i\!otlce'to Property Owners
About Construction Responsibilities
Note: Th{s Information Notice to Property Owners about Construction Responsibilitles
-was developed by the Construction Contractors Board in accordance with ORS 701.055(5).
If you are acting as your own contractor tD construct a new home or make a substantial improvement to an existing sIructure,
you can prevent many problem~ by being aware of the fDllowing responsibilities and areas Df concern. .
"
EMPLOYER RESPONSIBILITIES:
If you hire persons not registered witb the Construction Contractors Board tOdD labor in constructing or assisling in the
constructiDn or improvement of a residential structure, you will, in most instances, be ruled to I;le an emplDye. r and the people
. . .
YDU hire will be employees. As the emplDyer, you must cDmply with the following:
..
Oregon's withholding tax law: As an employer, YDU must withhold income taxes from employee 'wages at the time emplDyees
are paid. You will be liable for the tax payments even if YDU don't actually withhold the tax from YDur emplDyees. For mDre
information, call the OregDn Dep!. of Revenue at 945-8091.
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. FDr mDre information, call the Oregon Employment DivisiDn at the Department Df Human Resources
at 378-3524.
Workers' compensation insurance: As an emplDyer, you are subject to the Oregon WDrkers' CompensatiDn Law, and must
obtain workers' compensation insurance for your emplDyees. If you fail to obtain workers' cDmpensatiDn insurance, you may
be subject to penalties and will be liable for all clairn costs if one Df your employees is injured on the job. FDr more information,
call the Workers' CDmpensation Division at the Department of Consumer and Business Services at 945-7888.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be
liable fDr Ihe tax payment even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1-800-829-1040.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resDlving any failure tD meet code requirements
that may be brought to your attention through inspections.
Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray, water damage frorn pipe punctures, fire, or wDrk that must be
re-done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise tD act as your own general contractor, tD cODrdinate the work Dfrough-in and finish
trades, and tD notify building officials aI the appropriate times' so they can perform the required inspections.
If YDU have additional-questions, write or call the Construction Contractors Board,(PO Box 14140, Salem, OR 97309-5052,
503/378-4621). The Board is located at 700 Surnmer St. NE Suite 300, in Salem.
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