HomeMy WebLinkAboutPermit Mechanical 1989-12-29,{/5y
siPllI'{GFIELD
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springf ield, 0regon 97477
Offi ce :
INSPECTION LINE:
726-3759
726-3769
CITY OF SPR OREGON
Job Location:
Assessors Map #:
Owner:
Address:
City:
Value
5 Tax Lot #:
Phone #:
Insert:
eas e appropr a
Inspe t ion Requested:
or:
e app an ce
Z'lp:
Prel iminary Inspection 'is $15.00 (pri
Wood Stove/Insert Permit is $15.00 +
of
/nl\v I
Type of
Contract
Address:
or to 'installat'ion
$0.75 state surcha
of insert)
rge
o(-Phone #:
C'ity:State:
Construction Con actors Registration #:
r
gna ure
FOR OFFICE USE
By sign'ing this perm'it/appf ication, I agr^ee to cal I for an insrequired (726-3769). I also state that all information on thipermit is correct and that I was providecl w'ith the Wood Stovefor wood burning appliances and preliminary inspection standar
7.i p:
Ex pi res :
e
pection(s) as
s appl ication/
Safety information
ds.
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REQUIRED INSPECTION (S ) :I NSERT PREL IM I NARY
Date of Application:qb Job #:
Total Amount Collected:5
Rece'ipt #:Issued By:
froon.-h,lf-_4
Checked for Del'inquencies:\'/ Checked for Historical Status:
State:
Permit No:
Address:
lssued by
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential 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 Ooi t and either box 2A or 2Fi
1.l>*I I own, reside in, or will reside in the completed structure.
2. A. lF My general contractor is
Contractor registration number qprhl
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
OR
Date:
.''-.
WHITE COPY TO ]SSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT.,,
B I will be my own gener"i conlractor.
lf I hire subcontractors. I will hire onlv subcontractors reoistered with the
Construction Contractors Board. lf I change my mind and 6o hir,e a oerie-ralcontractor. I will contract with a contrattor-who is reoigtered'wIth the' Constructibn Gontractors B6ard and I will immediately-notify the office
issuing this building permit of the name of the contraitor.
l)
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.
x &*""P i) c'q4{X tLl?t - s
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 10t24t89
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