HomeMy WebLinkAboutPermit Mechanical 1994-10-19CITY OF SPR'A'GFIELD, OREGON
IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location:
SPFIII|GFIELO
0ffice:
INSPECTION LINE:
726-3759
7 26-31 69
Asses Map #:
Ovner:
Address:
Ci ty:State:
Value of !i oo d e/PelIet Stove/Insert :
a1
Type of InsPe ion Requested
Tax t *:
Phone: #:
Zip Code:
a6
Phone *:
Zip Code:
Expires:?fr\
PreliminarY InsPection is $15'
Vood Stove/Pellet/Insert Permi
fee + 510.00 issuance = 526'20
O0 (prior to installation of insert)
i-i.'sii.o0 * $.75 state surcharge + 9.45 administrative
Con t rac t
Address:
or:
Ci ty:
a lso understand hat
State:
ractors Registration #:Construction
By signing
(726-376e).
and that I
this permi t/aPP Iication, I agree to call for inspection(s) as required
1 state that a 11 the information on this permit/aPPI ication is correct
vas p rovided vi th the Vood Stove Safety information for vood burning
appliances and Pre Iiminary insP ection standards.I further state that the apPliance
I am installing mee ts smoke emi ssion standards as set bY the 0regon DePartment of
Environmental QualitY or the Federal Environmen tal Protection Agency and I agree to
rovide the testing roval- number to the insPe ctor at the time of insPection. I
p appif I am requesting a Prelimi nary inspection, the vaI1 covering
Issued BY
may be re to be removed.
t ure te
REOUIRED INSPECTION( S) :PRELIMINARY
Date of APP1ication:Job f:
Total Amount Collected
2
Receipt #\58 \
PELLET/IN
Checked for Deliquencies:
I/OODST
Checked for Historical Status:
Permit #:
Address:
Issued by:Date:o9q
Statement: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires resi.dential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building permit can be issued. This statement 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 appropriate blanks and initial boxes I and2, 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 4,-bEoS
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 notify the office issuing this building permit of the
name of the contractor.
I hereby certify that the is correct and thatl have read and dounderstand the Information
about on the reverse side of this form.
,/a -/t-7/
(Signature of permit applicant)
(White copy to issuing agency perrnit file,
pink copy to applicant)
OR
Notice
(Date)
\t-, -'-
Information Notice to Property Owners
About Construction ResponsibiIities
Note: T'his lnJbrmtttion Notice to Propcrrl,Owners about Construction Responsibiliiie.r*l:t*
was t{evelopetl hy the Con.struclion Cantractors Board in ar:<:ordance with ORS 70t.055(5).
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing structure,
you can prevent mcury problems by being aware of the lbllowing responsibilities and areas of concern.
EMPLOYER RESPONSIBILITIES:
If you hire persons.not registered .with the Construction Contractors Board {9 do labor in cons{ructing or assisting in the
construction or improvement of a residential structure, you will, in most instances, be ruled tg be an qmBloyer and the people
youhirewilIbeemployees,Astheemployer,youmuStcompIywiththefoliowing:
Oregon's withhotding tax law: As an employer, you must withhold income taxes from employee wages at the time employees
are paid. You will be liable for the tax payments even if you don't actually withhold thd tax from your employees. For more
information, call the Oregon Dept. 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 Departnrent of Human Resouroes
at378-3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must
ob-tain workers'compensation insurance for your employees. If you fail to obtain workers'comBensation insurance, you,may
besubjecttopenaltiesandwillbeliableforallclaimcostsifoneofyouremployeesisinjuredonthejob. Formoreinformation,
call the Workers' Compensation Division at the Department of Consumer and Business Services ad 945-7888.
U.S. Internal Revenue Service: As an employer, you must withhold federal iircome tax from employees' wages. You will be
liable for the tax payrhent even if you didn't actually withhold the tax. For more information, call the Internal Revenue Service
at 1-800-829-1040.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
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.
Liabili$ and property damage insurance: Contact your insurance agent to see if you have adequate irsurance coverage fcrr
accident$ and omissions such as falling tools, paint overspray, water damage from pipe punchres, fire, or work that must be
re-done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees
Expe'fiss' 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 building officials at the appropriate times se) they can perform the required inspections.
If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309-5052,
5031378-4621). The Board is located at 700 Summer St. NE Suite 300, in Salem.
prop-own.pm4
l/94
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPF!'{GFIELO
0ffi ce :
INSPECTION LINE:
726-3759
t26-3769
CITY OF SPR'A'GFIELD, OFEGO'V
Job Location:b z
Assessors MaP *:Tax Lot #:b /z
Ovner:,/,
Address:/),q,
Ci ty ate:
Value bf llo Stove/Pellet Stove/Insert :
Phone: #:
Zip Code:,7
Preliminarylnspectionis$15.00(priortoinstallationofinsert)
uood Stove/Pellet/Insert Permit i;'$ii:OO * $'25-siate sureharge * $'45 administrative
i;;-. S10.00 issuance = $26'20 total
Type of InsPection Requested:
Contractor:
Address:
Construction Contractors Registration *:
Phone #:
Zip Code:
Expires:
for inspection(s) as required
inspection, the va1I covering
By signing this P ermi t / app lication, I ag ree to caLl
(7 26-3769). I st a te that al I the informa tion on this Permit/aPP lication is correct
and that I vas P rovl ded vi th the Vood S tove SafetY informatio n for vood burning
app Iiances and Pre liminary insPe ction standards.I further state that the aPPliance
Iam installing me ets smoke emi ssion standards as set by the oregon Department of
Environmental QualitY or the Federal Environmen taf Protection AgencY and I agree to
rovide the testing aPP roval number to the at the time of inspection. I
p inspector
reliminarYalso unders that if I am requesting a P
may be to be renoved.
Total Amount Collected:
Receipt +, t( ? 78
-7
tegnature
REQUIRED INSPECTION(S)vOoDST OVE / PELLET / rN SERT-PRELIMINARY l-
Date of APP1ication:o Job *;
Issued BY:
Checked for Deliquencies:
a€)
Checked for Historical Statusi-