HomeMy WebLinkAboutPermit Mechanical 1994-12-02WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, Oregon 97477
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0ffice:
INSPECTION LINE:
726-3759
726-37 69
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-CITY OF OREGOA'
Job Location:20O N7.I
Tax Lot #:
Assessor_c Map #:
dJ-{0vner: fl r\u I 0-M I c\re \le efs
Address:,t
Ci ty:
Va1ue of Vood Stove/
Type of lnsPe ction Requested:
Contractor:
Address
Ci tY:
Cons t
f{e
State:
Insert:
Phone: *:
Zip Code:
7- l,LL
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Preliminary Inspection is $15'00 (pr
;;;a-;i;;*TP"ttLtzrnsert Permit is $
i"e-*-Sro.00 issuance = 526'20 total
ior to instalLation of ins
15.00 + $.75 state surchar
State:
ructi tractors Registration #:
ert
Phone #:
Zip Code
Expi res :
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OFFICE USE
INSERT PREL Y
Job #:
Issued BY
Checked for Eistorical Statusz-
)* $.45 administrative
Bysigningthispermit/appl_jc6tion,Iagre.etocallforinspection(s)aSrequired(726-3769). , ,,t"-,""ir,"f '"ii-.rr" inform-ation on this permit/application is correct
and that f vas provided vith the Vood Stove i-"t"ty informatibn for vood burning
appliances and p.liirl."ry inspecl;";-siandards. r further state that the appliance
I am installing meets smoke "ri;;l;; 'ttna"tat tt t"t by the .regon Department of
Environmental Quality or tf," f"a"ial Environmental ProteCtion Agency and I agree to
orovide the testing approval nu'ili- to the inspe"tor at the time of inspection' I
also understand thit if r am ,d;;;ti.,e ;-pr"r-ir-inary inspection, the va11 covering
,"V U" required to be removed'
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=============================--==========FOR
REQUIRED INSPECTION(S):
Date of APP1ication:
Total Amount Collected:
Receipt #:
llet St
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Checked for Deliquencies z
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D (-q'7'/ 7 -7
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Permit #:
Address 8f
AstIssued by:Date:
Statement: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon l-aw, ORS 701.055(4), requires resid.ential 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),
neednot submit this statement. This statement will be filedwith the permit.
Fill appropriate blanks and initial boxes I and2, and either box 3A or 38:
l. 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
(Name)
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
3B. 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 conffactor, 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 informationis correctand thatl have read and do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
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Contractor regis. #
OR
(Signature of permit applicant)
(White copy to issuing agency peftnit file,
pink copy to applicant)
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