HomeMy WebLinkAboutPermit Mechanical 1990-03-26UIOOO STOVE/INSERT INSPECTION_APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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Offi ce :
INSPECTION LINE:225 Fifth Street
Springfield, 0regon 97 477
7?6-3759
726-3769
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Job Locati on : e1 DV eu)vvt t,'lrt ar&
Assessors Map #:l-) D?, ?4l Tax Lot #: D ollb
Owner:
Addressr ? lr4 D \/',eu-t vv.,ot*ry.t-Phone *: 14a -oLob
Ci ty:State: OQ.Zi p:Q-l,l 1-7
Insert: "?,OOO Trl-t*S#,,*,Val ueo
(please c rcl e appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit 'is $15.00 + $0.75 state surcharge
Type of Inspect'ion Requested:?rU-+ .)+r,.or
Contractor:
City:State: OQ
Construction Contractors Reg 'istration #: aV
By slgninq !his permit/app'licat'ion, I agree to call forrequired (726-3769). I also state that-all information
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Phone #:1ulf..Sls;
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Ex p ires: I *t-qn
rrY correct and that I was prov idedurning appliances and prelimina
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FOR OFFICE USE
REQUIRED INSPECTION (S )/ I NSERT
Receipt #:Issued By:OB
an inspection(s) as
on th'is appl ication/
Stove Safety information
tandards.
3ieu, glL
Date -
PREL IM I NARY
with the Woodry inspection s
Date of Appf ication : 5 l>Ul o ,,
Total Amount Collected:
Job #:
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WOOD STO
Checked for Del inquencies:Checked for Historical Status:
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Address: H l,a{ C,ok,.r,.o O.0
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C.;C
Permit No:Qoo 3S, I
Address:
lssued by Date
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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 28
1 I own, reside in, or will reside in the completed structure
2. A. @ My g"n"ral contractor is
Contractor registration number
OR
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B.
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
I will be my own general contractor.
lf I hire subcontractors. I will hire onlv subcontractors reoistered with the
Construction Contractors Board. lf I chanoe my mind and tio hire a general
contractor. lwill contract with a contrattor'who is reoistered w'ith the
Constructibn Contractors Board and I will immediately-notify the office
issuing this building permit of the name of the contradtor.
I hereby certify that the above information is correct and that I have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse side ol this form.
3ieu lq n
o Date
CONSTRUCTION CONTRACTORS BOARD
0244J 10t24t89
t
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COFNT TO APPL]CANT
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