HomeMy WebLinkAboutPermit Mechanical 1994-12-20CITY OF SPR OFEGO'U
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, Oregon 91411
Job Location:
Assessors MaP f:
Ovner:
Address:
Ci ty:S tate :
Value of Uood Sto Stove
tal
Type of Ins pection Req ues ted:
SPFIl{GFIELD
0ffice:
INSPECTION LINE:
Tax Lot *:
Phone: #:
Zip Code:
25-3f5?=\u::L)
PreliminarY InsPection is $15'0
ilooa- sto.,eTpettltZlnsert Permi t
i;;-. S10.00 issuance = 526'20
0 (prior to installation of insert)
is S15.00 + $./s-;i;ie surcharge + $'45 administrative
Con t rac to
Address:
Phone #:
State:Zip Code:
Ci tY:
Cons t ructlon tractors Registration *:Expires:
By signing this permit/aPP lication, I agre e to call for insPe ction(s) as required
(726-376e) -I state that a I1 the informati on on this Pe rmi t / apP Lication is correct
and that I vas provi ded vi th the Vood Stov e SafetY inf ormat ion for vood burning
app Iiances and P reliminarY insp ection standards'I furthe r state that the aPP liance
Iam ins talling meets smoke em1 ssion standards as set bY the Oregon Departmen tof
Environmental QuaI i ty or thg Federal Environmenta I Protection AgencY and I agree to
inspector
preliminarY
at the time of inspection. _ I
p rovide the testing approval nunber to the
also understand tha t if I am requesting a
may required to be removed
ure
inspection, the va1I covering
Date
=============
========= =--= == = ===========================================================FOR OFFICE USE
REQUIRED INSPECTION(S) :VOODSTOVE/
IJ,, PRELIMINARY
Job *:
Date of APP1ication:
Tota1 Amount Coll-ected:
Issued BY:
ReceiPt #:
ser
/INSERT
Checked for Deliquencies:Checked for Eistorical Status:
-- 2--t
Permit #:
Address
Issued by:Date }D
Statem€nt: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before abuilding permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. Licensed
architect and engineer applicants, exemptfrom registration under ORS 701.010(7),
need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes I andZ, and either box 3,A, or 38:
1. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
3A. My general contractor is C\NttSkxxs,4utu5
-
U (Name)Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
38. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notiff the office issuing this building permit of the
name of the contractor.
I hereby certify thatthe above information is correct and thatl have read and dounderstand thelnformation
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
OR
tZ-Ze-?/
(Signature of permit applicant)
(White copy to issuing agency permitfile,
pink copy to applicant)
(Date)
Information Notice to Property Owners ,:,
About Construction Responsibilities . ,l , ,: .
Note: 'fhis l4f'onn*tion lrlatice to Property {)wne rs aboul C.'ttnstrut:tion Responsibiliiie: ,tt ':
v,as developed l>1,- the Construt:lion Coriractors Board in accorrlanr:e with ORS 701.A55$):-
ll you are acting as y()ur $wri c{)nlr&cior to conslrucl a nr:w liome or uraks a substantial improvement to an existing structure,
you can pre vent mzrny problems by being aware of the following responsibilities and aeas of coneern.
EM PLOYER RESPONSIBILITIES:
If you hire persons not registered with the Construction Contractors Board to ds labor in constructing or assisting in the
construction or improvement of a residentiai 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:
Orcgon's withholding tix law: As an employer, you must withhold incbme taxes from employee wages at the time employees
are paid. You will be liable for the'tax ilayments even if you don't actually withhold the tax from your employees. For more
information, call the Oregon f)ept. of Revenue at 945-8091
Unemployment insurance tax: As an employer, you are required to pay a tax for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Division at the.Departrnent of Hur:an Resources
ar 378-3524
Workers'compensation insurance: As an employer, you are subject to the Oregon Workers'Compensation Law, and musi
obtain workers'.compensation insurance for your employees. If you fail to obtain workers' compensation itrsurance, you.may
besubjecttopenaltiesandwillbeliableforallclaimcostsifoneofyouremployeesisinjuredgr-rthejob. Formoreinformation;
call the Workers' Compensation f)ivision at the Department of Consumer and Business Services at 945-7888.
U.S.{nternal Revenue Service: As an employer, you must withhold-fed'eral income tax fiom employees' wages. You will be
liable forthe tax paym€nt even if you didn't acfually withhold the tax. For more information, call the Internal Revenue Servicb
at l-80O-829-1040.
OTHEH RESPONSIBILITIES AND AREAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirernents
that may be brought to your attention through inspections. .
Liability and pnoperty danrage insurance: 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 punctures, 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 conlractor, to coordinate the work of rough-in and finistr
trades, and to notify building officials at the appropriate times so they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO Box l4l40, Salem, OR 97309-5052,
5031378-4621). The Board is located at 700 Summer St. NE Suite 300, in Salem..
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