HomeMy WebLinkAboutPermit Mechanical 1995-12-04ct TY OF I
SPClINGFIELI)
0ffice:
INSPECTION LINE:
225 Fifth Street
Springfield, 0regon 97477
Job Location:
Assessors Hap ll:
0vne
Addres
Ci ty:S ta te:
I 26-3
7
Value of d Stove/
Preliminary Inspection is S15.00 (prior to installation of insert)
Uood Stove/Pellet/fnsert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + 510.00 issuance = 52
Type of Inspection Request
6.2 o taI
Contractor:
Address:Phone #
Ci ty:S ta te:Zip Cpde
Cons truction Contracto Registration #:Expires:
By signing this permit/application,.f agree to call for inspection(s) as required
(726-3769). I state that aII the information on this permit/application is correct
and that I vas provided vith the Vood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I- am installing meets smbke emission standards as set by the Oregon Departmenf crf
Environmental Quality or the Federal Environnrcutal Protection Agency and I agree to
provide the testing approval number to the iuspector at the time of inspection. I
also understand that if I am requesting a prc).iminary inspection, the val} covering
may ber equired to be removed.
,/-\let Stove{nsert:\_ __..
Tax Lot S:
Phone: #:
Zi p Code:
Dategnaure
REQUIRED INSPECTI0N(S) : IJOODSTOVE/PELLET/
Date of Application:
Total Amount CoIlected:
FOR OFFI USE
PRELIMINARY
Job *:
Issued By,\q17fuReceipt #
-Checked for Deliquencies:-Uhccked for Historical tatus:
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINCFEILD
BUILDING SAFETY DIVISION
Fill in the
Statement: lnformation Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a building 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.
blanks and initial boxes I and2, and either box 3,A. or 38
Permit #:
,1 .H\r
Address:
Issued by:Date:
rn35q3
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
or upon completion.
3,A.. My general contractor is
(Name)
I will instruct my general contractor that all subcontractors
registered with the Construction Contractors Board.
(Signature of permit applicant)
Contractor regis. #
work on the structure must be
OR
3B. 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 building permit of the
name of the contractor.
I hereby certify that the above information is correct and that I have read and dounderstand the Information
Owners about Construction Responsibilities on the reverse side of this form.
ral 4lqz
(White copy to issuing agency perrnit file,
pink copy to applicant)
Notice
tout.i
r-
Information Notice to Property Owners
About Construction Responsibilities
Note: This Informa.tion Notice to Property Owners about Construction Responsibilities
wits cleveloped by the Constritctioh Contactrsrs Board in accordance with OnS ZOl.OSS1Sli.
If you are acting as your orvn contractor to construct a new home or make a substantral improvement to an er isting stntcture,
you can prevent many problerns by being aware of the following responsibilities and areas of concem.
EMPLOYER RESPONSIBILITIES:
If 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 employer, you must withhold incorne taxes from employee wages at the time employees
are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your employees. For more
information, call the Oregon Dept. of Revenue at 945-8091.
Unemployment insurance tax: As an employer, you are required to pay a tu for unemployment insurance purposes on the
wages of all employees. For more information, call the Oregon Employment Division at the Department of Human Resources
at378-3524.
Workers' compensation insurance: As an employer, you are subject to the Oregon Workers' Compensatioc Law, and tnrst
obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation insurance, you may
be subject to penalties 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 at the Department of Consumer a"n{ Business Services at 945-7888.
ar I-'ri''
U.S. Int0rnd Revenue Serviee .As anemployer, you must withhol$&doial freome tax from anployees' wages. You will be
liable for the tax payment even if you didn't actually withhold the tax. For mofe information, call the lnternal Revenue Service
ar l-800-829-1040.
OTHEH RESPONSIBILITIES AND AHEAS OF CONCERN:
Code compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code requirements
that may be brought to your attention through inspections.
Liabitity and property damage insurance: Contact your igsurance agent to see if you have adequate insurance coverage for
accidents and omissions such as falling tools, paint overspray, water damage from pipe punctures, fire, or work that must be
re-done.
Time to supervise employees: Make sure you have sufficient time to supervise your employees.
Expertlse: 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.
If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309-5052,
5031378-4621). The Board is located at 700 Summer St. NE Suite 300, in Salem. ,
prop-own.pm4
U94