HomeMy WebLinkAboutPermit Mechanical 1993-11-30c
CITY OF SP
IJOOD STOYE
RTNGFIELD
/INSERT INS PECTION APPITCATION
BUILDING SAFETY DIYISION
225 Fifth Street
Springfield, 0regon gl417
SPFI -.p;g1p
759
37 69
Job Location: /e, ?N frh) Ja^L.b-t ,C,
Assessors Hap *:)1 C za6 34 Tax Lot *:qoo
Ovner:
Phone *, 1)L 9&+a
Ci ty:State:A Zipz
Value of llood Stove/pe tIt store/Insert, #Sooo"(please circle appropri ate appliance
Preliminary Inspection is S15.OO (prior to installation of insert)Ilood stove/Perlet/rnsert permit is s15.oo + s10.00 rssuance + $.15 state surcharge
Type of Inspection Requested:Qpt oI'L ALnvs-
Contractor:,b*vtur
b{.J
Address:
Ci ty: State:
Construction Contractors Registration *:
Phone #:
.Zipz
E xpires:
Bys
(726
tha t
appl
fam
Envi
prov
also
may
igning this permit/application, r agree to carr for an ins pection(s) as required-3769). I state that all information on this application/permit is correct andI vas provided vith the Vood Stove Safety inf ormation for vood burning
1 ances and preliminary inspection standards.f further state that the applianceinstalling meets smoke emission standards as set by the oregon Department ofronmental Quality or the Federal Environmental Protection Agency and I agree toide the testing approval number to the inspecto r at the time of inspection. I
u erstand that if I am r equesting a prelimina ry inspection, the vall coveringuired to remov
ll
ture te
FOR OFFICE USE
REQUIRED INSPECTION(S): UOODSTOVE/
Date of Application: I t
Total Amount Collected: 6
Receipt *:
PRELIHINARY
Job *' of btf qz
Issued By:
Checked for Delinquencies u-"Checked for Historical Status z -/-
A
0ffi ce:
TNSPECTTON LTNE:
Address:
Q)+)'-)
=.d\ a,-
-?<
Permit No: q 3 t)3
Address:
lssued b
C._)tusl)?
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERSABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4) , require_s residential construction permitapplicants who are. not registereo wltn the Construction Contractors Board tosign the following statement before the building permit can be issued. This state-ment.is required for residential.b_uild.ing, eleclricat, mecnanlcii,-ino ptumoingpermits. Licensed Architect and Enginelr applicanis, exempt from registratioiunderORS 701.010(7), need not submit thid Statement. This statement wiil befiled with the permit.
Fill in the applicable blanks, and initial boxes 1 and z, and either box 3A or 38:
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is soldor offered for sale before or upon completion.
My general contractor is ,
Contractor registration number-.
1
2
Date:t' )toien
R OFFICE USE ON
WHITE COPY TO ISSU]NG AGENCY PERMIT FILE
PINK COPY TO APPLICANT
3 A
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
\3. B.l --Y I 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 lnformation Notice to Property Owners about Construction Responsibilities on the
reverse this form.
tlfsdqz
g ure o Pe rm cant DateA
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
/2