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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 zl p! 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 $: )i ty:State:z1 p! lonstructi on Contractors Reglstratlon *:Explres: y slgning this permit/application, I agree to call for an lnspection(s) as required 126-3769). f state that aII informatlon on this appllcatlon/permit ls correct andrat I vas provided vith the llood Stove Safety lnformatlon for wood burnihg rpliances and prellmlnary lnspectlon standards. I also understand that if I am rquestlng a prelimlnary lnspectlon, the vali coverlng may be requlred to be removed. 7a+rd'/zc*%*Z-{, /"?/ fnature :J Date FOR. OTFICE USE IIOOD \r'=/UrRED INSPBCTIoN(S) lpt t: : of Appllcatlon: rI Amount Collected:S PRELIHINARY Job *: /INSERT ked for Delinquencies: Lssued BY: Checlced for Historical Status:t"/ Permit No: Address: lssued Date OFFICE USE ONLY J I Note: Oregon Law, ORS 701.055(4), requires residential building_permit applicants who are not registered with the Construction Contractors Board to sign the following staterient before the building permit can be issued. Licensed Architect and Engineer applicants, exempt from registration under ORS 701.010(7), need not subhit thid itatement. This statement will be filed with the permit. Fill in the applicable blanks, and initial box 1 and either box 2A or 28: STATEMENT: INFORMATION NOTICE TO PROPERTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES I own, reside in, or will n the structure. 2. A.My general contractor is EContractor registration number OR reverse side of this form' gnature t p CONSTRUCTION CONTRACTORS BOARD 1 I will instruct my general contractor that all subcontractors who work on the structu r" .r.t'f,"ili i Jt.iJJ *itn in. construction contractors Board. B I will be my own general contractor' ent.,ffigff ,g15i$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 @: h.' ni q t-a lr 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. {6,d ztL.*/a?/ 7 ( 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 J REQUIRED INSPECTION(S) : IIOODSTOVE/PELLET/INSERT (\ ^^,-----