HomeMy WebLinkAboutPermit Mechanical 1991-10-21OF SPR"UGFTEU,., OREGO'V
VOOD STOVE/INSERT INSPECTI . APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SP'II'tGFIELE,
0ffice:
INSPECTION LINE:
726-3759
726-37 69
Job Location:, f/ru4'fou EP
Assessors Hap *t,co7 /?, Btocr</, hEsfas 4</es
0vner: /q<./Pr29 fauc v/i@EL
'/1 Tax Lot *:
Address2 rgef 7lc,zgrary ,ee
Ci ty z, gt",ltNCP/EuO
Value of Uood Stov
(please circl e aPpropr a e appliance)
Preliminary Inspection is $15.00 (prior t
Ilood Stove/PeIIet/Insert permit is g15.OO
Type of Inspection Requested
Phone *z l?6 *t76 7
State z GrK zi p:<t7q79
nsertz / zoctc,''o
o installation of insert)
_+ S10.00 Issuance + $1.25 state surcharge.
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Contractoy, ctZAFI Srol/E C Erv74.2
let S
Address | /g'75 t/ES7 6rs .ltzE Phone #: ?y;- 6frs
Ci ty z EuaEry€,State. o rt-Zipt 771o2
Construction Contractors Registration *:Expires:\D,ZBq
By signing this permit/application, I agree to call for an inspection(s) as required(726-3769). I state that aII information on this application/permit is correci andthat I vas provided vith the llood Stove Safety infoimation for vood burningappliances_1nd preliminary inspection standards. f further state that the applianeeI am installing meets smoke emission standards as set by the oregon Departmenl ofEnvironmental Quality or the Federal Environmental protection Ag-ncy.na r agree toprovide the testing approval number to the inspector at the time of inspection. falso understand that if I am requesting a preliminary inspection, the vaII covering
may be required to be removed.
,r'""-lZ 4/qt.z-Zl oct 7tSignatureDate
FOR OFFICE USE
REQUTRED TNSPECTION(S) :LIUINARY x
Date of Application:Job *:
TotaI Amount Collected:
Receipt *:
..'t {_a^-T
PELLET/INSER
Checked for Delinquencies:
Issued By:
Checked for Historical Status:
Permit No:
lssued Date:
OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residentia! 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 the applicable blanks, and initial box 1 and either box 2A or 28:
1
2. A.
OR
I own, reside in; or will
My general contractor
Gontractor registration
is
number
in the pleted ructure
i
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
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 my mind and -do hire a general
contractor. lwill contract with a contrattor-who is reoistered w-ith the
Constructibn 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 side of this form.
ignature t pp cant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 1/90
Ji.'JL
I
@s
Address:
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