HomeMy WebLinkAboutPermit Mechanical 1992-12-14OF SPR OREGO'U
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAPETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
Job Location:
Assessors Hap *:,)
Ovner:
Address:
Ci ty S ta te:
SPRINGFIELD
A1
0ff i ce:
INSPECTION LINE:
726-3759
726-3769
Tax Lot *:
Phone #:
/Pellet Stove/fnsert: I
ease circle appropriate appli
zi
/INSERT PRELI},TNARY
Job 1[:
p:1
Value of
(pI
Uood Stove/
Type of Ins
Contractor:
ance
Preliminary Inspection is S15.00 (pr ior to installation of insert)Pellet/fnsert permit is$15.00 + S10.00 Issuance +$82.5 state surcharge.
ion Request ,7?
Address:
Ci ty:
Phone #:
S tate:zi p:
Construction Contractors Registration #:Expires:
By signing this permi t/application , f agree to call for an. inspection(s) as requi red
-
(72 6-3769). r s tate that aII info rmation on this appli cation/permit is cor rect andthat f vas provi ded vi th the Uood Stove Safe ty informat ion for vood burn irgappliances and preliminary inspect ion s tandards f fur ther state that the appliancef am installi ng meets smoke emissi on standards as set by the Oregon De partment ofEnvi ronmen taI Quali ty or the F'eder'aI Environmen ta1 Pro tection Agency and f agree toprovide the t esting a pproval number to the ins pector at the ti meofi nspection. falso underst and t t if f am reques t ing a preliminary inspecti oDr the vall coveringmay be i red be
ture
FOR OFFICE USE
Da te
REQUIRED INSPECTION(
Date of Application:
TotaI Amount Collect ed
Receipt #:
S
Checked for Delinquencies:
fssued By:
Checked for Historical Status:
-
Permit No:
Address:
lssued Date
OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4) , requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt f rom registration
under ORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
Fill in the plicable blanks, and initial boxes 1 and 2, and either box 3A or 38
'fl.r
1
2
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
My general contractor is ,
Contractor registration num
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
above information is correct and that I have read and understand
OR
3.A
3.B
I hereby certify that the
the lnformation Notice
reverse sid f this
ture of
CONSTRUCTION CONTRACTORS BOARD
0244J B/91
Property Owners about Construction Responsibilities on the
m pl t te
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT