HomeMy WebLinkAboutPermit Mechanical 1992-10-07SPRIrl.GFIELE,
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INSPECTION LINE:
QfrUOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location:
Assessors H"p *t
0vner:
Address:
Ci ty:State!
?26-3759
726-3769
Tax Lot *:
Phone *:
.zip:
Preliminary Ins pection is 915.00 (prior to installation of inser t )Vood Stove/
Type of Ins
Con t rac tor :
Pe1let/Insert per is 515.00 +s10.00
Value of
(pl
,t--'::tove/Pelle0 Strcle\ffiriaease ci
u1 to ere
e+state surcharge.
pection Requeste
Address
Phone *:
Ci ty:State:Zipz
Construction Contractors Registration #:Expires:
inspee t
By signing this permi t/application , I agree to caII for an ion(s) as required(726-3769). r s tate that all inf ormation on this applicat ion/pe rmit is correct andthat f vas provi ded vith the Vood Stove Safety inf ormation for vood burn ingappliances and p reliminary inspect ion standards.f further state that t he applianceIam installing meets smoke emission st andards as set by the oregon De partment ofEnvi ronmen taI Quality or the Federal En vi ronmental Protection Agency and I agree toprovide the t esting approval number t o the inspect or at the time of i nspection. Ialso underst and that if f am r equesting a prelimi nary inspection, the vall covering
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may ed.b
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POR OFFICE USE
REQUIRED INSPECTION( S) :
Date of Application:
Total Amount Co lected:
Receipt #:
PRELTMINARY
Job #:
t ,-rd'r c,ry OF SPR OREG ON
fnsert
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Checked for Delinquencies:
I ed
Ch'ecked for Historical Status:
Permit No:
Address
Date:
R OFFICE USE ON
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
1
2
3.A
plicable blanks, and initial boxes 1 and 2, and either box 3A or 38
I own, reside in, or will reside in the completed structure.
I understand that I must reg ister as a construction contractor if the structure is sold
or offered for sale before or upon com letion
My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work
ture must be registered with the Construction Contractors Board.
+u5C ni
fiMlqI-
gv
OR
the
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
3.8 I will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf 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
reverse side of this form.
/0 -- - 7L-
gn re Perm pp Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
t t
lssued
INFO*ffiATION NOTICE TO PROPERTY CMNERS
ABOUT CONSTRUCTION RESPONSIBII.ITIES
NOTE: This lniormation Notice to Property Owners About Construction Responsibilities
_was developed by the Construction Contractors Board in accordance with ORS 70{-055(5},
'passed by the 1989 Oregon Legislature. :'
lf you are acting as your own contractor to construct a new home or make a substantial improrement to an
existing structure, you can prevent many problems by being aware of the following responsibilitfes and areas
of concern.
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the conslruction or improvement of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will be "employees". As the employer, you must comply with the following:
9regon's Withholding Tax Law: As an employer, you must withhold income taxes from emptoyee wages at
the time employees are paid. You will be liable for the tax payments even if you don't actually withhold the
tax from your employees. For more information, call the Oregon Department o{ Flevenue at 378-33g0.
Unemployrnent lnsurance Tax: As an em ployer, you are required to pay a tax for unemployment insurance
For more information, call the Oregon Employment Division DHRpurposes on the wages of all employees.
at 378-3224.
Workers'Com nsation lnsurance As an employer, you are subject to the Oregon Workers' Compensation
Law, and must workers'compensation insurance for your employees. lf you fail.to obtain workers'
compensation insurance,yo u may bb su bject to pen
information,
alties and will be liable for all claim costs lf one of your
employees is injured on the job. For more callthe Workers' Compensation Division DIF at 373-7434.
U.S. lnternal Revenue Service: As an employer, you must withhold federal income tax from employees'wages.
ymentevenifyoudidn,tactuallywithholdthetox.Formoreinformation,iall
the lnternal Revenue Service at 221-3960.
OTHER BESPONSIBILITIES AND AREAS OF CONCEHN
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be brought to your attention through inspections.
Liability and Property Damage lnsurance: 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 Employees: Make sure you have sufficient time to supervise your employees.
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify buildinE officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
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