HomeMy WebLinkAboutPermit Mechanical 1991-10-15CITY OF OBEGO'U
/CCD STOVE/INSERT INSPECTI*. APPLI,CATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location:
Assessors ila p *:
Ovner:
Address:
Ci ty:
Value of il e/Pellet St
( please c1e appropria
Preliminary Inspection is $15.00
Uood Stove/Pellet/Insert permit
!
Type of Inspec Reques ted
Contractor:
Ci ty:
Construction Contractors Registration *:
S ture
Tax Lot *:
Phone *:
State:zi p:
(prior to installation of insert)is $15.00 + 310.00 Iss +S .25 state surcharge.
S tate:zip:
Expires:
Date
FOR OFFICE USE
/PE
SPFI}'GFIELE,
0ffice:
INSPECTION LINE:
%
726-3759
726-3769
D
By signing this permit/application, I agree to caII for an inspection(s) as required(726-3769). I state that all information on this application/permit is correct andtha_t I vas provided vith the l{ood Stove Safety information for vood burningappliances-and preliminary inspeetion standards. I further state that the applianceI am installing meets smoke emission standards as set by the oregon Departme;t ofEnvironmental Quality or the Federal Environmental Protlction ag-ncy.na r agree toprovide the testing approval number to the inspector at the tim6 of inspectiln. Ialso understand that if I am requesting a preliminary inspection, the vaII coveringmay be required to be removed.
REQUTRED INSPECTION(S) :
Date of Application:
I
5
Total Amo
Receipt #
unt Colle ed:
Job *:
I
nsert:
/INSERT
Issued
Checked for Historical Status:
Address:
-
Phone #:
/r)- /i-q/
Checked for Delinquencies:
IJOOD STOVE/INSERT INSPECTION APPLICATION
CITT OF SPRINGFIELD
BUILDING SAFETY DIVISION
!SPRIItlGFIELO
Offlce:
INSPECTION LINE:
L/,GB
225 Fifth Street
Springfleld, 0regon 97477
726-3759
726-3769
CITY OF SPR OREGO'U
Job Locarion: ee!3 Atr lJo rn =--:#rec- f
Assessors llap #r )-lOa f,.Si? tax Lot f,:
owner: Yac\&-zrni ^r l- VY,&g>e-
CSJOO
Address:a)Q3 N , AC,&J Sfizz_f phone #r 13L'-7+-7 t)
Ci ty:State:OQ zl p!.t)q 1-7
Value of lfood Stove/Pe1let Stove/Insert:
(please clrcle approprlate appllance)
Pr.ellminary Inspection ls
Wood Stove/PeIIet/Insert
Type of Inspeetion Reques
GoO'(prlor to installatlon of -insert)
Permlt ls $15.00 + $10.00 Issgance + $1.25
ted: Q*-/, vv-(\t v.\c+/V+< l? I -cu t
state surcharge.
W.S"rt
contractor: TI^.o - C*r,.{+ S{-,w-G".,,c
lQ-v'
Address:l?ls \,J l- tu A^a-Phone $:_I ?s:os33
Ci ty:Q*,^r.,*-State:OQ zlp: 911/0)
lres:Y
By slgning this permlt/applicatlon, f agree to call for an lnspection(s) as required
(726-3769). I state that all lnformatlon on this appllcatlon/permlt is correct and
that I vas provlded vlth the llood Stove Safety lnformatlon for wood burnihg
appllances and prellmlnary lnspection standards. I also understand that if I am
rlquesting a prllimlnary inspettlon, the vali coverlng may be requlred to be removed.
-
vConstruction Contractors Reglstration *:
PD-,/^-,r-, / ,1-,-*, -7- ,ta -7/Vffnature--' -Date
FOR. OFFICE USE
REOUIRED INSPECTION(S) : IJOODSTOVE/PELLET PRELIMINARY
Date of Appllcation:Q -to.q t Job *: 4 ttcbr{
Tota1 Amount Collected:15 oct
CAReceipt $:Issued By:
Y
^ lf,
Checked for Delinquencies:Checlced for llistorical Status , f
/
Permit No
Address:
lssued
,(2 )&ot1
(\*.,L 1 T,{,I
OR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential building permit applicants
who are not registered with the Construction Contractors Board to sign the
following statement before the building permit can be issued. 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 applicable blanks,and initial box 1 and either box 2A or 28
1 I own, reside in, or will reside in the completed structure
A.My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
OR
2
B.I will be my own general contractor.
lf I hire subcontractors. I will hire only subcontractors reoistered with the
Construction Contractors Board. lf I chanoe mv mind and Eo hire a oeneral
contractor, I will contract with a contrattor'who is reoistered with the
Construction Contractors Board and I will immediately-notify the office
issuing this building permit of the name of the contraitor.
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 side of this form.
q
t, )/fl_
CONSTRUCTION CONTRACTORS BOARD
0244J 1t90
rt.Ct-WHITE CIPY TO TSSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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