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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. ) 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: r--;r \