HomeMy WebLinkAboutPermit Mechanical 1993-03-24VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SP;II1{GFIELE,
0ffice:
INSPECTION LINE:
Zx
726-37s9
726-3769
CITY OF OFEGO'V
Job Location: /l1e /rn/A Dn/4 ,f/.
Assessors Hap *:a
n 77/77 7ooh.
Tax Lot *:
ovner: /.or' ,4nn 4cTa"rnt4
ood St
Ci ty:
Value of
Contractor: .
Address :
-Ci ty:_ ;
Address:/r'fa /%r-A Tert/A,f/.Phone *: 7r'6 -3b6q
zrp'-v? v77
Phone *:, te IY
Zipt
Date
4e State:o<
Ilet Stove/Insert:I boo
( pre ase c r e appropriate appliance
Inspection is $15.00 (prior to installation of insert)ellet/rnsert Permit is $15.00 + $10.00 rssuance + $.15 state surcharge.
Type of Inspect on Reques ted:cth Do/
t tV-|f
Construction Contractors Registration #:Expires:
By signing this permit/application, I agree to call for an inspection(s) as required(726-3769>. I state that aII information on this application/permit is correci andthat I vas provided vith the llood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the applianceIam
Envi
prov
tu
REQUTRED TNSPECTTON( S) :
Date of Application:
Total Amount Collected
Receipt fl:
State:
FOR OFFICE USE
VOODSTOVE / PELLEI / TN SERT PRELIHINARY
Job *:
installing meets smoke emission standards as set by the Oregon Department of
ronmental Quality or the Federal Environmental Protection Agency and I agree toide the testing approval number to the inspector at the time of inspection. I
understand that if I am requesting a prelininary inspection, the vaII covering
be required to be removed.
eq 73
Ilood St
Checked for Delinquencies:
Issued By:
Checked for Historical Status:
)
Permit No
Address:
lssued Date:
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 plumbingpermits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not sudmit this statement. Thii statemeit wiil befiled with the permit.
Fill in t applicable 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 before or upon completion.
My general contractor is ,
Contractor registration number-.
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
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 hirea 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.
certify that the above information is correct and that t have read and understandrmation Notice to Property Owners about Construction Responsibilities on theside of this form.
OR
2
3.4
3.B
I hereby
the lnlor
c-t( -C
nature mit
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
Date
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
+tr
I
r.l .,
INFORil}TION NOTICE TO PROPERTY OW(IERS
ABOUT CONSTRUCTION RESPONSIBILITIES
'. ..-, !1..,
lf ybu iie acting as your own contractor'to construct a new home or make a substantlhl fnp?ryem.ent to an
existing structure, ypu gfln preyent mq.ny problems by being aware of the following responsibllities and areas
of concern t
EMPLOYER RESPONSIBILITIES
lf you hire persons not registered with the Construction Contraclors Boar:Ctp do labor in constructipg or assisting
;;'* i"""!irr"iia-n or improVement of';;;id";ii"J rtirarri!, you witl, in most ingarices, U=alruled to be an
"emptoyer ugd ih".fleople you hile wtll bg "employees'.l As-the emplgyer, Vou must'cbmply with the following:
n's Withholdi Tax Law As an employer, yo-u
, i..
musi withhold.income idxes from{employee wages at
the time em oyees are paid. You will be liable for tt'1e tax payments even if you don't actually withhold the
tax from your employees. For more information, call th e Oregon Department of Fevenue at 378-3390
Une ent lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurance
purposes on t
at 378-3224.
wages of all employees., For more i nformation; call the Oregon Employment Division DHR
Workers'Com ion lnsurance: As an emPloYer, You are subiect to the Oregon Workers' Compensation
Law and must ln compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you may be subject to penalties and will be tiable for all clairn costs if one of your
employees is injured on the job. For more information, callthe Workers' Compensation Division DIF at 973'7434
U.S. lnternal Revenue Service: As an employer, you must withhold federal income,tSl from employees' wages.
,"ntL,6nltv|lioion'tactiiattywi[nrrotothetax],Formoreinformation,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
coAe requlrements that may be brought to your attention through inspections.
Liabi and lnsurance: Contact your insurance agent to see if you have adequate insurance
coverage for ents and omi s such as falling tools,paint oversptay, 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 contractor, to coordinate the work
oi rouffin and finish irades, 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, OH 97310-0151
Phone 5ffi-3f&4621
NOTE: This lnforrpation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701055(5),
passed by the 1989 Oregon Legislature.
o244J 10124189