HomeMy WebLinkAboutPermit Mechanical 1994-12-19aCITY OF OREGO'V
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springf i.e1d, Oregon 97 477
Job Location:
Assesso f
0vner:
Addr
Ci ty:S ta te:
Value of Vood Stove Pe1let Stove/Insert:
total
Type of InsPe ion Req ues ted :'
Contractor:
Address:
^.i +r,. S tate:
Construction Contractors Registration #:
nay red to be removed.
ture
Bysigningthispermit/appljgst.ion,Iagreetocallforinspection(s)aSrequired
(726-3769). r stlte thai'a11 the informition on this permit/application is correct
and that I vas provided vith the Vood Stove Safet-y infornation for vood burning
appriances and prlririnrry inspecilo;-siandards. r furrher state that the appliance
I am installing -;;;i; ,*'ok" "rl""lt" standards as set by the gregon Department of
Environmentaf Quality or the Federal Environmental Protection Agency and I agree to
orovide the testing approval. ,urU"i to the inspector at the time of inspection' I
!il"'ria"r",rJ that if r am r"qrl..i"e ;-pi"iiminary inspection, the vall covering
.45 administra ve
Phone *:
Zip Code:
Expires:
Date
==============-- ==================--===========
SPFINGFIELr,
0ffice:
INSPECTION LINE:
726-37s9
t 26-37 69
Tax Lot *:
4zsgo
PreliminarY InsPection is $15'
Vood StoveTPetlet/Insert Permi
fee + S10.00 issuance = 526.20
00 (prior to installation of insert)
i-i"'Sii.00 + $.75 state surcharge + $
q
OFFICE USE
REOUIRED INSPECTION(S) :IIOODS
Date of APP1ication:
Total Anount Collected:
Receipt #:
Job *:
Issued BY:
/INSERT PRELIMINARY
{'
1t
Phone: *:
Zip Code:
Checked for Deliquenciesi-Checked for Historieal Status:
,/_
Permit #:
Address:
Issued by:Date:.lq
Statemert: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants wha are not registered with the Construction Contractors Board to sign the
following statement before abuilding permit can be issued. This statement is required
for residential building, electrical, mechanical, and plumbing permits. 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 appropriate blanks and initial boxes I and2, and either box 3A or 38
1. I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
4-bS-es3,A.. My general contractor is
(Name)Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
38. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
registered with the CCB and will immediately notify the office issuing this huilding permit of the
name of the contractor.
I hereby certify that the above information is correct and thatl have read and dounderstand thelnformation
about Construction Responsibilities on the reverse side of this form.
- f./
OR
(Signature of
(White copy to issuing agency pennit file,
pink copy to applicant)
Notice to
'Z @^a
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