HomeMy WebLinkAboutPermit Mechanical 1992-10-13CITY OF OFEGO'V
IJOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
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0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:>17:a S rlb=]L- tr
Assessors Map *:rax Lot *: O{6Cil
0vner:Dltert -<.I tlu9
Address z 4 4;>s t+ L+^ Sr
Ci ty:State:
ert:6 ziT),oz)cle ap Iiance)
Preriminary rnspection is $15.00 (prior to instarration of ins
Lrood stove/Perlet/rnsert permit is 915.00 + $10.oo rssuance +
Type of Inspection Requested:
Contractor:e
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Phone *:T rta - q4t'i
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Value of Vood St
(please cir
ert )
W state surcharge.
)Address:
Ci ty:State:zipt q74 Dl
Construction Contractors Registration #:i qvb Expires:p -u -q3
Phone *:v4. tt>[
Datd f 1
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also
igning this permit/application, I agree to call for an inspection(s) as required-3769). I state that all information on this application/permit is correcf andI vas provided vith the Uood Stove Safety information for vood burningiances and preliminary inspection standards. I further state that the applianceinstalling meets smoke emission standards as set by the 0regon Departmeni ofronmental Quality or the Federal Environmental Protection Agency "na I agree toide the testing approval number to the inspector at the time of- inspection. Iunderstand that if I am requesting a preliminary inspection, tfre vatt coveringbe required to be removed.
t. /t= )rz--gna u
FOR OFFICE USE
Pellet St
REQUIRED INSPECTION(S) :
Date of Application:
TotaI Amou
Receipt #:
nt CoIIect
PRELIMINARY
J b *:
'ELLET/
Checked for Delinquencies:
Issued By:
Checked for Historical Status:
ffl'-0
--
Fill in
Permit No:
Address
lssued Date:
R OFFICE USE ONLY
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS701.055(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 registration
under ORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
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 upo nco mpletion.
1
2
OR
3.A 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.
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 Information Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
lo*t3-?z-
gna rmit pplicant Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8t91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
3
INFORn ATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSTBILITIES
lf you are acting as your own contractor to construct a new home or make a substantial improvement 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 construbtion 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 income 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 Department of Revenue at 378-33g0.
Unemployment lnsurance Tax: As an e mployer, 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 DHFI
at 378-3224.
Vo-rker-s- Compensation lnsurance: As an employer, you are subiect to the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance for your employees. lf you fail to obtain workers'
compensation insurance, you rnay be subject to penalties and will be liable for all claim costs if one of your
employees is injured on the job. For more inforrnation, callthe Workers' Compensation Division DIF at 973-14U.
U.S. lnternal Revenue Service: As an employer, you must withhold federal income tax from employees'wages.
ymentevenifyoudidn,tactuallywithholdthetax.Formoreinfoimation,caIl
the lnternal Flevenue Service at 221-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
t-!qo Qrnellglge: As the permit holder for this proiect, you are fesponsible for resolving any failure to meet
,.cde requirements that may.be brought to your attention through inspections
Liabil and lnsurance: Contact your insurance agent to see if you have adequate insurance
coverage r accr dents and omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re,done
Time to Supervise Emd"oyees: 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
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 97310-0151
Phone 503-378-4621
NOTE: This lnformation Notice to Property Owners About Construction Responsibilities
was developeO Oy the Construction Contractors Board in accordance with ORS 701.0SS(S),
pas.sed by the 1989 Oregon Legislature,I
0244J 1A124189