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HomeMy WebLinkAboutPermit Mechanical 1990-03-26UIOOO STOVE/INSERT INSPECTION_APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION !5PFTl{GFTELD Offi ce : INSPECTION LINE:225 Fifth Street Springfield, 0regon 97 477 7?6-3759 726-3769 Ia-I caI 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 *'l-^c-d{ Phone #:1ulf..Sls; Zi p : 1) Ex p ires: I *t-qn rrY correct and that I was prov idedurning appliances and prelimina 1 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 #: rw WOOD STO Checked for Del inquencies:Checked for Historical Status: -!--- Address: H l,a{ C,ok,.r,.o O.0 / I 6l tnni o C.;C Permit No:Qoo 3S, I Address: lssued by Date t]+))6t []JR 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 <,r-las< 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 @s a l,,un \/ ie,^ ),,l',.ntr,u.t .