HomeMy WebLinkAboutPermit Mechanical 1994-03-28SP-TiIGFIELD
0ffice:
INSPECTTON LINE:
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth StreetSpringfield, 0regon gl4l7 726-3759
726-3769
CITY OF OREGO'U
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Job Location:O ,ah)
Assessors Map *:_ l, Caa s) I
0vner:
Address:,eh)
Ci ty:State: /')A
Value of llood Stove/pellet Stove/Insert 4(please circle appropri ate appliance
Tax Lot *: f)r)
Phone #: -l L" - lqqq
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state surcharge.
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Preriminary rnspection is g15.oo (prior to instarration of insert)Ilood stove/Perret/rnsert permit is'$ts.0o + g10.00 rssuance + g.lg
Type of Inspection Requested:
Contrac tor:
Address:
Ci ty:State:
-
zip:
Construction Contractors Registration *:Expires:
By signing this permit/applicationl I agree to caII for an ins pection(s) as requlred(726-3769). I state that all information on this application/permit is correct andthat I vas provided v ith the lIood Stove Safe ty information for vood burningappliances and prelim inary inspection st andards f further state that the applianceI am installing mee emission standards as set by the Oregon Department ofEnvtal Quali e Federal Environmental Protection Agency and I agree tothe test ing number to the inspect or at the time of inspection. Irstand tha am requesting a prelimi nary inspection, the vaII covering
3 4
Date
OFFICE USE
REQUIRED INSPECTION( S) :INSERT PRELIMINARY
Date of Application: 3 Job *:
Total Amount Collected:S.?C
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Receipt +: ))Oqn
Checked for Delinquencies:
Issued By:
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Checked for Historical Statusz L--'
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Date:
OR OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITTES
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 from registratioi
under ORS 701.010(7), need not submit this statement. This statement will befiled with the permit.
Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
Permit No:Q2t a
lDvo N r .tflvtlO
lssued uv, DB tu
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 numbe
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
YY., q,h''
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.
1
2
3
OR
A
3,8
I hereby certify that the
the I ion Notice
of this form.
CONSTRUCTION CONTRACTORS
0244J 8191
ation is correct and that I have read and understand
Owners about Construction Responsibilities on the
3f >g lqu
Date
WHITE MPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
Address:
I will be my own
INFORM)IfION NOTICE TO PROPERTY OWflERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This lnformation Notice to Propefty Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1989 Oregon Legislature.
lf you are acting as your own contractor to construct a new home or make a substantial impi6vement to an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern.
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will be "employees". As the employer, you must comply with the following:
Oregon's Withholding Tax Law: As an empkryer, you must withhold income taxes from emplOyee wages at
uwillbe1iableforthetaxpaymentsevenifyoudon'tactuallywithholdthe
tax from your employees. For more information, call the Oregon Department of Revenue at 378-3390'
Unemployment lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurance
mployees.Formoreinformation,calltheoregonEmploymentDivisionDHR
at 578-3224.
Workers' Compensation lnsurance: As an employer, you are subject to the Oregon Workers' Compensation
pensationinsuranceforyouremployees'lfyoufailtoobtainworkers,
compensation insurance, you may be subiect to penalties and will be liable for all claim costs if one of your
empioyees is injured on the job. For more information, callthe Workers' Compensation Division DIF at 573-7434.
U.S. lnternal Revenue Service: As an employer, you must withhold federal income tax from employees'wages.
ymentevenifyoudidn'tactuallywithholdthetax.Formoreinformation,call
the lnternal Revenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
Code Compliance:
code requirements
As the permit holder for this project, you are responsible for resolving any failure to meet
that may be brought to your attention through inspections.
Liabi and lnsurance: Contact your insurance agent to see if you have adequate insurance
coverage ents omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees Make sure you have sufficient time to supervise your employees.
Expertise-: Make sure you have the expertise to act as your own general contractori to coordinate the workof rough-in and finish trades, and to notify building officials at thi appropriate times so they can performthe required inspections.
lf you have additional questions, write to: Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 9^310-0151
ozuJ 1,t24t*s phone 503-97M621