HomeMy WebLinkAboutPermit Mechanical 1993-05-10VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
€iPFtxcFtELO
0ffi ce:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Hap *:Tax Lot *:
Ovner:
Address Phone *:(
Ci ty:State:zi p:
Value of St Ile st
(please circle priate
Preliminary Inspection is
Ilood Stove/Pellet/Insert p
$15.00 (prior to installation of insert )
IS 15.00 + $10.00 Iss +19 qta surcharge.
Type of I tion Request n
Contractor:
Address Phone *
Ci ty:State:Zipz
Construction Con tors Registration *:Expires:
By signing this permit/application, I agree to caII for an inspection(s) as required(726-3769). I state that aII information on this application/permit is correci andtha_t I vas provided vith the lJood Stove Safety infoimatton for vood burningappliances and preliminary inspeetion standards. I further state that the appliancer am installing meets smoke emission standards as set by the 0regon Departmeni ofEnvironmental Quality or the Federal Environmental Protlction AgEncy.na r agree toprovide the testing approval number to the inspector at the time of inspecti6n. Ialso understand that if I am requesting a preliminary inspection, the viII covering
may be required to be removed.
{-/o-?3
ture Date
FOR OFFICE USE
REQUIRED TNSPECTT0N(S) :
Date of Application:Job *:
TotaI Amount CoIIected:
Receipt #:
CITY OF OFEGO'U
Insert:
PELLET/INSERT PRELIHINARY
Issued By
Che for Historical Status:Checked for Delinquencies:
Permit No
Address:1tt
5lssuedDate:
R 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.
int icable blanks, and initial boxes 1 and 2, and either box 3A or 38
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 b
2
3
upon com
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.
3.8 I 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.
I hereby certily that the above information is correct and that I have read and understand
the lnlormation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
Signature o rm t cant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8191
plelrco.iio
OR
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
,5--/O- ?3
TNF.RMAT'J, *o*cE To pRopERrv owrveis
ABOUT CONSTRUCTION RESPONSIBILITIES
lf you are acting as your'Own conftdctbr to construct a new home or make a su bstantial to an
existing stru cturg,,y-gu:-gpqqlevent many problems by being aware of the following responsibilities and areas
of concern
EMpLOyER RESpONSIBILITIES: .,r:j', i. ' .-. ,": '''!i'.ir-..
lf you hire pefg-o.tl:,!o.t registered with the Qonstruction Contractors Board to do lapor i1 constrqcllpg or. assisting
in the construbti'bhqI lrhpgf6rnent'0f'h)resld-ential btructure, you will, in most jqgtii.'ri.c..e.s, b6-t'iuled to be an
"emptoyer" a[d i6e.peopre'you rrire will be "e,fup.loyees'i As. q[e .eJlployer, vpy;pir?t cbriibrv Wiin tne following:
Oregon's Withholding Tax Law: As an employer, you must withhold incorne taxes from employee wages at
uwillbeliableforthetaxpaymentsevenifyoudoh,tactuailywithholdthe
tax from your employees. For more information, call the Oregon Department of.,Revenue,at 378-3390.
U nemployment lnsurance Tax As an employer, you are required to pay a tax for unemployment insurance
purposes on the wages of all employees. For.,more information, call the Oregon Employment Division DHR
at 378-3224.
Workers'Compensation lnsurance: As an employer, you are subject to the gregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensatton lnsurance, you may be subject to penaltios and will be liable for all claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at 973-7434.
U.S. lnternal Revenup Service: As an employer, you must withhold federal income tpx from employees'wages.
mentdvenityoLdidn'tabtuallywiinnotcjthe.tax.'Formoreinfoimation,call
the lnternal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code iequirements that may be brought to your attention through inspections.
Liqq!iryandProper.w@Contact1iourinsuranceagenttoseeifyou.haveadequateinsurance
coverage for accidents and omissions such as falling tools, paint overspray,.Wdter damage from pipe punc-
tures, fire, or work that must be re-done.
Time to superv ise Employees Make sure you have sufficient time to superuise your employees,
'j
Expertise: Make sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to:Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR S/310{151
Phone 503-tr/84621
A
NOTE: fhis lnformation Notice to Property Owners About Construction Besponsibilitbs
was developed by the Construction Contractors Board in accordance with ORS 7O1.055(5),
azMJ 10t24t89