HomeMy WebLinkAboutPermit Mechanical 1991-03-04WOOD STOVE/INSERT INSPEqTION APPLTCATION
CITY OF SPRINGFIBLD
BUILDtrNG SAFETY DIVISION
SPRIII|GFIELD
0fflce:
INSPECTION LINE:
225 Fifth Street
Springfleld, Oregon 97477
726-37s9
726-3769DCh
CITY OF SPF OREGO'V
Job Location:3\\O Or\
Ci ty:SDftfl-
Assessors Map *:\r)3
0wner:
Address:
Tax Lot *:\ a(.t o
Phone *:--t
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surcharge.
l"D cbe-,
State:
Value ", U"")rStove/Pellet Stove/Insert :
(please circle appropriate appl
Pr.erlminary rnspectlon ls $15.00 (prior to instarration of.insert)
uood stove/Pel1et/rnsert Permlt ts $15.00 + $10.00 rssuance + $1.25 sta
Type of Ins
Con trac tor:
[ddress:
peetion Requested:
Phone $:
)i ty:State:z1 p!
lonstructi on Contractors Reglstratlon *:Explres:
y slgning this permit/application, I agree to call for an lnspection(s) as required
126-3769). f state that aII informatlon on this appllcatlon/permit ls correct andrat I vas provided vith the llood Stove Safety lnformatlon for wood burnihg
rpliances and prellmlnary lnspectlon standards. I also understand that if I am
rquestlng a prelimlnary lnspectlon, the vali coverlng may be requlred to be removed.
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fnature :J Date
FOR. OTFICE USE
IIOOD
\r'=/UrRED INSPBCTIoN(S)
lpt t:
: of Appllcatlon:
rI Amount Collected:S
PRELIHINARY
Job *:
/INSERT
ked for Delinquencies:
Lssued BY:
Checlced for Historical Status:t"/
Permit No:
Address:
lssued Date
OFFICE USE ONLY
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Note: Oregon Law, ORS 701.055(4), requires residential building_permit applicants
who are not registered with the Construction Contractors Board to sign the
following staterient before the building permit can be issued. Licensed Architect
and Engineer applicants, exempt from registration under ORS 701.010(7), need
not subhit thid itatement. This statement will be filed with the permit.
Fill in the applicable blanks, and initial box 1 and either box 2A or 28:
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
I own, reside in, or will n the structure.
2. A.My general contractor is
EContractor registration number
OR
reverse side of this form'
gnature t p
CONSTRUCTION CONTRACTORS BOARD
1
I will instruct my general contractor that all subcontractors who work on
the structu r" .r.t'f,"ili i Jt.iJJ *itn in. construction contractors Board.
B I will be my own general contractor'
ent.,ffigff ,g15i$t1*r+l**'*"6,tmu"-kd'ii}{'ii-lr''iid
r hereby certify that the above information is correct and that r have read and understand
the rnformation Notice to propertv iiiln"ri.rout conitiuction Responsibilities on the
1t
COPY TO ISSUING AGENCY PERMIT FILE0244J 1/90
COPY TO APPLICANT
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OFEGO'VCITY OF
VOOD STOVE/TNSERT INSPECTION APPLICATTON
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPBI,{GFIELO
0fflce:
INSPE TION LINE:
225 Fifth Street
Springfield, 0regon 97477
726-3759
726-3769
(.'Job Locatlon:Ito
Assessors Hap *:Tax Lot $:lz> eo.1 l/lr'1
Address:Ztt? Or; o(e Phone *: 1>b - 70 /?
Ci ty:Se€d State:o z7 p:lz4tt
Va1ue of llood Stove/Pellet Stove/Insert:
(please clrcle approprlate appLlance)
Pr.ellminary Inspection ls $15.00 (prior to installation of-insert)
Wood Stove/Pellet/Insert Permit ts $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:
Con trac tor:
Address: Phone *:
Ci tyt State:zlp:
Construction Contractors Reglstratlon *:lres:
By slgning thls permlt/applicatlon, I agree to call for an lnspection(s) as required
(726-3769). I state that all lnformatlon on thls appllcatlon/permlt ls correct and
that I vas provided vlth the Uood'Stove Safety lnformation for vood burnihg
appliances and prellmlnary inspectlon standards. I also understand that if I am
requesting a prelimlnary lnspectlon, the vali coverlng may be requlred to be removed.
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Signatuie te
FOR. OFFICE USE
Date of Appllcatlon:7-L6-?t
Total Amount Collected:
Receipt *:llaz7 Issued By:
l-tt'
PRELIMINARY
Job #:? t orbt
Checked for Delinquencies:Checlced for llistorical Status z t-'
Owner:
'D r o [rr^ iY.a rvt
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REQUIRED INSPECTION(S) : IIOODSTOVE/PELLET/INSERT
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