HomeMy WebLinkAboutPermit Mechanical 2004-08-31Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
5 4l -7 26-37 69 Inspection Line
Building/Combination Permit
PERMIT NO: COM2004-01090ISSUED: 0813112004APPLIED: 08/3112004
EXPIRESz 0212812005
VALUE:
SITE ADDRESS: 626 28TH ST
ASSESSOR'S PARCEL NO.: 1703361111800
PROJECT DESCRIPTION: Installwoodstove
owner: JEAN STEpHANIE sroNE REvocABLE TRUS
Address: 626 28TH ST SPRINGFIELD OR 97477
Springfield TYPE OF WORI(: Wood Stove
TYPE OF USE: New
Contractor Type
Mechanical
Contractor
KEITH LEESMAN
Expiration Date
04t04t2005
Residential
Phone
541-995-6157
License
72082
CONTRACTOR INFORMATION
BUILDIN(
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
R-3
\rN
#of
Dist:
# Street Trees Rqd:
Paved Drive Rqd:
Yo oflot Coverage:
Lot Size:
Sq Ft lst Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
REQUIRED PARKING
Total:
Ilandicapped:
Compact:
nla
$ Per Sq Ft
or multiplier
Square Footage
or Bid AmountDescription Type of Construction
Total Value of Project
Date Calculated
',
10
'\9
VaIue
F
Status Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676Fax
541-7 26-37 69 Inspection Line
Building/Combination Permit
PERMIT NO: COM2004-01090ISSUED: 0813112004APPLIED: 08/3112004
EXPIREST 0212812005
VALUE:
Fees Pa
Fee Description
-Mechanical Issuance Fee-
+ l0o/o Administrative Fee
+ 7%o State Surcharge
Minimum/Adj ustment Mechanical
Wood Stove/lnsert
Total Amount Paid
Amount Paid Date Paid
8t3u04
8t3u04
8t3U04
8t3u04
8t3u04
$10.00
$4.s0
$3.1s
$15.00
$30.00
Receipt Number
r200400000000001287
r200400000000001287
1200400000000001287
1200400000000001287
1200400000000001287
$62.65
Plan Reviews
To Request an inspection call the24 hour recording at 726-3769. All inspection requested before 7:00 a.m.
will be made the same working day, inspections requested after 7:00 a.m. will be made the following work
day.
Wood Stove: After Installation.
red Insnections
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springlield and the Laws of the State of Oregon pertaining to the work described herein, and
that NO OCCT PANCY will be made of any structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project.
I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the
street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all
times construction.
tfir*u f-3 /'0 (
or Contractors Signature Date
Pase 2 oI2
J ffiL
225 Fifib Street
Springfield, Oregon 97 47 7
541-726-3759 Phone
^rty of Springlield Official Receipt
--;velopment Services Department
Public Works Department
RECEIPT #: 1200400000000001287 Date: 0813112004 e:55:03AM
Job/Journal Number
coM2004-01090
coM2004-01090
coM2004-01090
coM2004-01090
coM2004-01090
Description
+ 7o/o State Surcharge
+ l0% Administrative Fee
Wood Stove/Insert
Minimum/Adjustment Mechanical
-Mechanical Issuance Fee-
Amount Due
3.15
4.50
30.00
15.00
10.00
Item Total:$62.65
Payments:
Type ofPayment Paid By
CheckNumber Authorization
Received By Batch Number Number How Received Amount Paid
Check JEAN STONE djb 5479 In Person $62.65
Payment Total:
-56ffi
813r/2004 Page I of I
-l
Construction Contractors Board Permit #: LOr^zoOrt - A tO 7 O
700 Summer St ItlE Suite 300
PO Box 14140
Salem OR 97309-5052
Phone: 503-3784621
WebAddress:ryfu1!31!4
Address 6zb z8+Q s +
Issued by:\6 Date: I -)-o(-f
Jx
X
Statement: lnformation Notice to Property Owners
About Gonstruction Responsibilities
Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not
licensed with the Construction Contractors Board to sign thefollowing statement before a building
permit can be issued. This statement is requiredfor residential building, electrical, mechanical and
plumbing permits. Ltcensed architect and engineer applicants, exemptfrom licensing under
ORS 701.010(7), need not submit this statement. This statement will befiled with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3,A. or 38
l. I own, reside in, or will reside in the completed structure.
2. I understand that I must become licensed as a construction contractor if the structure is sold or
offered for sale before or on completion.
tr 3A. My ge,neral contractor is
(Name)(ccB #)
I will instruct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
OR
Jt 3B. I will be myown general contractor.
If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
licensed with the CCB and will immediately notiff 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 do understand the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
8 -3i -04
(Signature of permit applicant) @ate)
(lVhite copy to issuing agenq) pennilfile, pink copy to applicant.)
Property_onmer. doc 06-0 I -04
--t^.
Yonr Own General Contractor?Acting as
INFORKIATION NOTICE TS PRSPENTY OWNHRS
ABOUT SON$TRUCYION RESPON$*BILITIES
If you are acting as your own conkactor to construct a new home or make a substantial improvement to an existing
structure, you can prevent many problerns bybeing aware of the"'follswingresponsibilities
Employer Responsibilities
You will, in most instances, be rutred to be an 'oemployer" and the contractors yolr $ontract with will be "ernployees" if
ysu u$e conkactors nol triee*sed witir the Corstrucfion Contraotors Board to do trabor in ccn*tructing or tc assi*t in th*
c*flstruction or improve:nent $f a residenti*l stflrcfrrre . As the empl*yot', y$ll urust comply with the folluwing:
®oxrs Wi*lah*ldiag ?ax Law: As an employer. you *:ust rrithhs)ld ineome taxes fi'orn enrpl*y*e lvag*s at the time
eixptoy*es are paid. Y*u wii! be liable ftr the tax payments ev*x if y*u d*n"t actualty witl:h*id tt:* tax fr*rn y*ur
er*pl*ye*s. Fsr rnclr* i$f$ffxatiqm, call the Oepar*uent *f Revenue at 503-3?8-4988"
tlxl*mptroym*nt Xcsmr*xl** Txx; A* an empl*yer, you ere required tCI pay a tax for r":nempl*yrnent insurxrce Ptrqpo$es
*n the wase$ *f atrl*nipl*yees. F*r m*re informati*n, ealt thc *r*gt;n 6rxryI*yr*e*t **p*r*x*nt at 5*3-94?-1485.
Ti:e {k*g** Susixsss Xdentificati*r: N*rnber {SX}.:} is ;i combined number fr:r both Oregon Withirolding and
1l*empi*5,1x*r:t Xrrsur;an** Tax" ?c fllc {br a B}N, cal} 5*3-945-E0sl cr 1yu:1-.-rfurr-:;tate,*LgVjp:u:g$rl!trftPlj" f*r the
appropriate forms.
Weirkerco C6x6p*xcsm{iq}& }*surasrce; As an *mpi*yer, y$u are subj*ct to the &r*g*r: Wc}rkers' C*ntpc.*sati*n l-aw,
a*d rxust *bt*in wcrkers' **mpensati*n insi:ran*.* f*r yow employees. If you faii t* obtain w$rk*rs' ccrnpe*sation
in$utranee, yor: c*x1d l:e s*hj*ct to penalties anci be liable for all elai*r c*sts if *ne gf yorr *npl*yees is injured *n the
j*b. Fq:r *:l*r* infurmari*n, eatrl thE Wclrkers' C*rnpw*ati*n Division at the Depa*rnent of Consumer ar:d Exs.i*ress
Serviees at 5{i3*}4?-?8 i 5 "
U.$" Ixrterr*x3 Kevcxlxe $**"viae; As:an emp3*yer, y*u rnxst withhr:ld federal income tax &*rn rmployees'wagei.'
yslu wili'be tiahle Jbr iir* rax pe),mrnr rvrn if you dirS:"r'{ *cewei}y with}r*lx} t}':* t*x. h't:r a F*qlera} fiIN n*r*bcr, *allthe
trRS at 1-800-S29-4933 *r visit their wetr site at XXIr ll-$.gllY
{}tfuer Kespcmsibtlit*e* axr$ Aree$ $f Ctlncerms
Csde C*nep[*.x11c*: A* the B**:r:it h*]c3*r for Chi* prr:jee{, }r** *r* r*sp*:ns:hl* for r*s*lving, any fartrlrre *o rnesr cosJ,r
requirerxenf$ t?let nlxy }:e ?:r*ug}:lt {o your *tl*rti*r: thr*ugh insprcii*ns.
€,*ahiilty xaxal 3;rarp*rty Xlnm:ag* Xmsarxxr**t Ccnt*lci y*xr insxr**** ag*xt t* s** if y** hav* a<lrqxette insr:ra*ee
o*r,uru6* i{}r *il*i**::ts xr:,"tr *::*i*s;*a:r s,**h *s i*3ling t**}s" p*int ov*r $3}ruy" w;lt*r *amag* lrr:in p!p* pu*I{*r*s, *r* *r
v. #rii t.hn'" rnr i f l r* i''. . ic-r: .
Y*xrser h.{ak* surq: y*x i:avc sxlfieierll ttm* ?* sup*rvise y*ur *r*pi*3***s' :
S.xp*s.€isc: h.X*k* "",rr" '"i.!{, llil!c 111p cfut}}> t{} ecl ai tr{,}ur o\1 n gcn*rri crrnlriclsr. t{} co(rrdir'!aic i}:r-- rvt,rl: *i r$llgh-in
*ori fi*i*i* tr*r1cs, *nd t* r:*lily 1:xilclix6 *flfiei*l* a$ trh* *ppr*;:rial* ti*l*s s* l,1r*y *n:: p*rii:rn: thr; r*q*ir*d i:"rsp**ti*ns"
and concerns
If ycx hav* aiJ;Ji.tr*:;:a{ qu*sti*ns call th* C*xstnr*tion Co::.tr**t*rs *oarl3 (}(}}-3?&-4{i?1} *r r.rr*t* t}:* agelr.*v at P{}
S*x tr414fi, $*lexx. {11{ $13*$-5*53. : , . :i+,, j ,.
Property' u\\.,r('t.ct{1\ {iP.tt : -:1 ;
NOTE: This lnfarmafion lVofbe to Property Owners about Construction Responslbi/ilie$ tryas develap*d by the
Consfrucfion Cantractars Eaard in ac*ardance with ORS 70r"055(5J, passed by ttt* 1989 Aregan L*gislatur*.
SPm*t${iF**LI} ,:i
225 FIMH STREET O SPRINGFIELD, OR 97477 o PH:(541 726_3753 o FAX:1)726-3689
CityJob Number
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Job
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Owner:€rt ^) 5, StA ^,e
Address:+Phone:7-
City:.(',PR i n/cil t.t-h State: O zip:
Preliminary Inspection is $45.O0 (priqltolilsert)
wood Stove/peilet/lnsert rermil6TeZSE-(Doludes Permit, Issuance Fee, State Surrharge and Administrative Fee)
lnformation
*=r Phone: ?y f -Arf7
State: 4:r{L zip:9)?VL
a Expires:q-q - oY
By signing this aStee to call for an inspection(s) as required (726-3769\
I state that all apphcatton/pernrit is correct andthat I was provided with
Date of Application:
\/' Checked for Historical Status:i
7
Contractor:
Address:
City:
Construction
Checked for Delinquencies:
8--OL(
Shared Drive(T:)/Building Foms,lWood Stove Pemrit 3-04-04.doc
GFIELD, OREGONCITY OF
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FOROTFICE