HomeMy WebLinkAboutPermit Mechanical 1994-10-06VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRTNGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SP,lIilGFTELD
0f f ice:
INSPECTION LINE:
726-3759
726-3769
CITY OF OREGON
Job Location:
Assessors MaP #:6
Ovner:
Address:
Ci. ty:S tate :
Value of i,rood Stove/PeIIet Stove/Insert:
Type of InsPection Requested:
Tax Lot #: f O 5az>
Phone: *:
Zip Code:
ea
s Tzuzez
ZD<",
Prel-iminary Inspection is $15'00 (pr
;;;a-st;;i?Pettertrnsert Permit is $
i;; ,. S10.00 issuance = 526.20 total
ior to instal-lation of insert)
fi.OO-* $.75 state surcharge + $'45 administrative
Contractor;a
Address:Phone #:
Zip Code:Ci ty: State:
Construction Contractors Registration # i- Expires:
By signing this permit/app.l.ig3tion, I agree to caII for inspection(s) aS required
(726_3769). r 'tlt" 1i'ai'.Li the inform-ation on this permit/application is correct
and that r vas provided vith the vood stove safety information for vood burning
appliances and p.'Jimi.,ary inspeclio., "tandards. I further state that the appliance
I am installi.ng -r""i; irot " "ri"ti", standards as set by the oregon Department of
Environmental ou.iity or. the Federal Envj.ronmental Protection Agency- and r agree to
provide the ,""r1r,i-'.pproval nu*Ult to the inspector at the time of inspection' I
also understand that if r am r"qr""airg a
-preriminary inspection, the vaI1 covering
may be required to be rernoved'
,/?-/, - /,/
Dateure
=======================================================================================FOR OFFICE USE
'//
REQUIRED INSPECTTON(S): V00DST0 ,,@N
Date of APP1ication:
Total Amount Collected:2_o
Receipt #:1422+
Job #:
Issued BY:
INSERT PRELIMINARY
Checked for Del-iquencies:
2/o
Checked for Historical Status"-
?n,3 3/
-2
Permit #:
Address: 2d 3 A^/, /8z F=
Issued by:Date:
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Statement: lnformation Notice to property owners
About Construction Responsibilities
Note: Oregon l-aw, ORS 701.055(4), requires residential constructton 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 fited with the permit.
Fill in the appropriate blanks and initial boxes I and2, and either box 3A or 3B:
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.
(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.
KX
OR
X 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 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.
trz^ rz fu*fu)
(S ignature rt {"r"rrt applicant)
(White copy to issuing agency pennit ftle,
pink copy to applicant)
/(Date)
-/
3,A,. My general contractor is
/