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Home My WebLink AboutPermit Mechanical 1992-1-7 SPRINGFIELD WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth S,treet Springfield, Oregon 97477 'Office: 26~3759 INSPECTION LINE: 726-3769 } 5" S S' tIiJ. ya tJ J] t2tiJ!:e' /2tJ iJI) Assessors Map 1I: ~I O~ q:5 ~ ~ f)A1U2~L L. /C~~S is s-:;- fhW~ i$I~CU2-. f}b4D City: Sp(0AJ6 h~w State: () R l ~tVo Job Location: Tax Lot 1I: O(J I OeJ Owner: Address: Phone 1I: Zip: c; 7it7 7 Value of Wood Stove/Pellet Stove/Insert: (please circle appropriate appliance) Preliminary Inspection is $15,00 (prior to installation of insert) . Wood StovelPelletlInsert perm,iti\s $15,~0 + $ ,75 state surcharge + $10,00 Type of InspeC;,tion Requested~ ~~ n lun ~ lJ\~ ' Contractor: (JrYrl. l\oi1.0- -ffioIDO \)1\~ Address:~~Q.~ ffi'\tn ,Sm-Qj)t -'-/ ;hone Ci ty: ~ State: (\It) construct~on\c~ractors Registration 1I: ~t~~ Issuance, lI:I4\o-(02-2-1 ZiP:tt{(5' Expires: ?Z.~, ~ 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 Wood 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 un~~and that ife;pem requesting a preliminary inspection, the wall covering ~ma:~e ~1~i)0 L r%t~ 117 /9.P ~nat~ (' Date FOR OFFICE USE REQUIRED INSPECTION(S): WOODSTOVE~T;;NSEri) >C. PRELIMINARY 0 Date of Application: /-B-q;J --JOb 1I:- q{;)()()/Io / 4(),I~ (_ /) _ r-. J , ,Issued B~{ ~ Total Amount Collected: Receipt 1I:?A1~ Checked for Delinquencies: Checked for Historical Status: .;I.t .... ..' , . . Permit No: 0; ,Qonr ( 0 'Address: \ ~r:-n cN1 urb n Brl. PC l. 'U/ - (\ 1')0 Issued by( f\!.lJr)::. ).." Date: f - 0-1 ,9. FOR OFFICE USE ONLY STATEMENT: 'INFORMATION NOTICE TO PROPERTY OWNERS' ABOUT CONSTRUCTION RESPONSIBILITIES Note: Oregon Law, ORS 701.055(4), requires residential construction permit. applicants who are not registered with the Construction Contractors Board to .,', sign the following statement before the building permit can be issued. This state, ment 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-ap'plicable blanks, and .initial boxes 1 and 2, and either box 3A or. 3B: r-f ./ - 1. I '-!..... I I own, residein,or will reside in the completed structure. '.'" 2. I I understand that I must register as a construction contractor if the structure is sold, or offered for sale,before or upon completion. ' () 3. A.I rllJl My general contractor ie' (~!)ryQ~ 1.)0 1)_ ~ ffiptn 'J-.-? " Contractor registration ,number A I o~ 3 . ',I will ,instruct ,my general contractor that all subcontractors who work on the struc- ture must be registered with the Construction ' Contractors Board. '. " OR 3. B. I ...[ I will be my own general contractor. ;. , .:. '.. ", '11'1 ,hire subcontractors, I will hire only subcontractors registered with the Construc:, lion Contractors Board., If I change my'mind and do 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. ". .. 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, ,', reve~e Sij:r:;~CmC Ie . " / ) 7/9 ~ Signarure of Permit APP~ ' DatEY I CONSTRUCTION CONTRACTORS BOARD 0244J 8/91 WHITE COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT ~ INFORaTION NOTICE TO PROPERTY O.ERS ABOUT CONSTRUCTION RESPONSIBILITIES , , " -. NOTE: ' , 'This Information Notice to Property Owners About Construction Responsibilities was develojJea by'the-Construction C'oni'ractors Board in accordance with ORS 701,.055(5), , pass,:d by, th.e 19~9 Oregon Legislature. . ' ,> If you are acting asyour own contractor to construct ,a new home or make a substantial improvement to an existing structure, you can prevent many problems by being aware of the following responsibilities and areas 'of concern. ' : . " , . EMPLOYER RESPONSIBILITIES: , ho, ,.' If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the construction or improvement. of a residential structure: you will, in most instances, be ruled to be an "employer" an'd the people you hire will be "employees". As the' employer, yciu must comply with the following: -. . . .. ~ _ 4 I' Oregon's Withholding Tax Law: As an employer, you must withhold 'income taxes from employee wages at the time employees are paid. You will be Itable for the tax payments even if you don't, actually withhold the tax from your employees. For morJ'inforrmltion, call the Oregon Department of REJVfilnue at. 378-3390. Unemployment Insurance Tax: As an employer, you a'ie required to pay a tax for unemployment insurance purposes on the wages of all employees. For more information, call the Oregon Employment Division DHR at 378-3224.' ' , " " " . Workers' Compensation Insurance: As an employer..you are s!Jbjec!,o,the.Oregpn Workers' Compensation Law, and must ob,tain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may be subject to penalties and will be liable for all claim costs if one of your employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 373-7434. , .1 '.. ...,' . . , U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the taxpaymerit.even if'you didn'l'aCtually withhcild'the tax. 'For'more information, call the Internal Revenue Se'rvice at. 221,3960. ,'.' . r' -. .' , . OTHER RESPONSIBILITIES AND AREAS OF CONCERN: ". "', .., Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements, that may. be brought t() 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 from pipe punc- tures, fire, or work that must be re.done. Time to Supervise Empioyees: ,Make sure' yay have sufficient time to supervise youremploye~s. '. . Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work of rough-in and finish trages, and to notify building officials at the appropriate times so they can perform the required inspections. If you have additional questions, write to: Construction Contractors Board 700 Summer SI. NE, Suite 300 Salem, OR 97310-0151 Phone 503-378.4621 0244J 10/24/89