HomeMy WebLinkAboutPermit Mechanical 1990-11-07CITY OF SPR'A'GFIELD, OREGON
SPFIIIGFIELD
IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRTNGFIELD
BUILDING SAFETY DTVISION
225 Fifth Street
Sprlngfield, Oregon 97477
Job Locatlon:
Assess s Map #:
0vner:
Address:
Ci ty:
Type of Ins
Contractor:
Address:
0ffice:
INSPECTION LTNE:
726-3759
726-3769
Tax Lot *:
Phone *:
State:Zlp:
SctR-
CPValue o t Stove/Insert:
(pI e appropr iate appliance
Preriminary rnspection is $15.00 (prior to instarration of insert)
llood Stove/Pe1let/Insert Permit is $15.00 +state surcharge + $10.00 Issuance
pec t Reques ted
Phone #:
Ci ty:State:zi p:
Construction Contractors Registration #:Expires:
By signing this permit/application, I agree to eall for an inspection(s) as required(726-3769). I state that aII information on this appl-lcatlon/permlt is correc[ andthat f vas provided with the llood Stove Safety information for wood burning
appliances and preliminary inspection standards. I also understand that if I am
req uesti ng a preliminary inspectlon, the waII covering may be required to be removed.
ture Da te
FOR OFFICE USE
L-/REQUIRED INSPECTION( S) :
Date of Application:
Total Amount Collected:
Receipt #:
/INSERT PRELIMINARY
Job #r5
I\j
Checked for Delinquencies:
Issued By:
Checked for Historical Status z '-./
Permit No:
Address:
lssued Date
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITI ES
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 box 1 and either box 2A or 28:
1 I own, reside in, or will reside in the completed structure.
2. A.My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
OR
\4WD
I hereby certify that the above inlormation is correct and that I have read and understand
the lnformation Notice to Property Owners about Construction Responsibilities on the
reverse of this form.
// -7- lO
rm can Dat6
CONSTRUCTION CONTRACTORS BOARD
0244J 10t24189
I will be my own general contractor.
lf I hire subcontractors. I will hire onlv subcontractors reoistered with the
Construction Contractors Board. lf I chanoe mv mind and -do hire a oeneral
contractor, lwill contract with a contrattor'who is reoistered with the
Constructibn Contractors Board and I will immediately-notify the office
issuing this building permit of the name of the contraitor.
B
UiAk"opy ro rssurNc AGENcy pERMrr F'LE. P}O( COPY TO APPLICANT,:r}ftc,
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