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Home My WebLink AboutPermit Mechanical 1992-9-4 ~OOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LIN~_'Lb-376~ ,,) - cQqS4; \<<\f\n\ ~)X\\~ 'ld Assessors Hap #: \lD?l~~?J~ ;ax Lot #: CXNYJ ~ Owner: ~~'{\ 0 ,t(~ ~l\f) Q ~ ~. Address:ClC\~ ~ f$~( . Phone #: \9Jn' (d)t01 ~ State: (UJU Zip: Q,j I I Pellet Stove/Insert:&\ \nn~ .. appropriate appliance) Job Location: City: Preliminary ,Inspection is $15.00 (prior to installation. of insert) ~ood Stove/Pellet/Insert Permit is $15.00 ~ $~O.OO Issuance + $1.25 state surcharge. Type of Inspection Requested: ~~<::J eL Contractor: ~ ~ \n Ll- l ~ci Sml "P ~ Add"", ?I 010/ ,:''i{ ()[) }$i~rmQ'lfi )"",., IJCB=-- fll13 City: ( trlnO Q J.J\ State: Nf ) Zip: q{3...~?J Construction Contractors Registration #: (011 /J'?] _Expires: n . 4 ,l.1~ By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was provided with the ~ood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the wall covering ~= ;Ie z;ed)y11 , /Signature r f-/f -7' <- r Date FOR OFFICE USE Total Amount Collected: Receipt #: (0 II 'I REQUIRED INSPECTION(S): ~OODSTOVE/PELLET~SER~') ~ Date of Application: t:j.~. C17~ Job #: c{)f:l, fJ~ I Issued BY:~ ~ Checked for Historical PRELIMINARY qA \ \ ?-{) Checked for Delinquencies: Status: ;) . . Permit No: q Q 1/3'1 ) Addrn", ~~I{64 fiUJ1f'JV Issued by ~ Date' cj1-t?2,;- ~ ' FOR 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 from registration under ORS 701.010(7), need not submit this statement. This statement will be filed with the permit. Fill i~ t~apPlicable blanks, and initial boxes 1 and 2, and either box 3A or 3B: 1. I -r I I own, reside in, or will reside in the completed structure. I 2. I . I I understand that I must register as a construction contractor if the structure is sold . or offered for sale before or ;!1?on completion. C' b 3. A.I lL:?MY general contractor is (=:1~ Cn...LL.... \.t... ') ,-3L.lJl es ( Contractor registration number l Q \ \~-~ .0 I will instruct my general contractor that all subcontractors who work on the struc- ture must be registered with the Construction Contractors Board. OR 3. B.I I I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors registered with the Construc- tion Contractors Board. If 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 certify 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. r~~t~irc CONSTRUCTION CONTRACTORS BOARD 0244J 8/91 C;.~ /J -/ 2- , Date WHITE COPY TO ISSUING AGENCY PERMIT FILE PINK COPY TO APPLICANT .' -._- INFOI'ATION NOTICE TO PROPERTY ~NERS ABOUT CONSTRUCTION RESPONSIBILITIES NOTE: i, \ Th!s Inf~rma~on Notice.to Property Owners About Construction Responsibilities . was develop'ed QY tl}fl:c::onstruction Contractors Board in accordance with ORS 701.055(5), , pass~d 'QY ~he f1989, Oregon Legislature. \ \ If 'you are aciing '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. "', ""J " " EMPLOYER RESPONSIBILITIES: If you hire persons not registered with the Construction Contractors Boa,rd 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 alJ.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 Departm~nt of :Revenue at 378-3390. , . - . ~ ' Unemployment Insurance Tax: As an employer, you are required to pay a iax'for unemployment insurance purposes on the wages of all employees. For more in(ormation" call the Oregon Employment Division DHR at 378-3224. ...' , '^/orkers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insuraflce 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, cali the Workers' Compensation Division DIF at 373-7434. U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will be liable for the tax payment evem if you didn't actualiy withhold the tax. For more information, call the Internal Revenue Service at 221-3960." " ' OTHER RESPONSIBiliTIES AND AREAS OF CONCERN: , vode Compliance: As the permit holder for this proji'!ct, you are respo.nsible for resolving any failure to meet 80de requirements, that may be bro,ught to your attention through inspections. Liability and Property Damage Insurance:, Contact your inswance agent to see if you have adequate insurance coverage for accidents and omissions such as faliing 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 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 to: Construction Contractors Board 700 Summer St. NE, Suite 300 Salem, OR 97310-0151 ' Phone 503-378-4621 0244J 10/24/89 Job Location: ,,{)q~,+ \ J\'{)_noe) fit Assessors Map #: \ () (J~ a 3o~ ,Tax Lot #: Owner: '- 0XJ 0 V NY) f\ (\1\(\ u )- D('(1 Address: c9- q~ \"roJ\Qy [)t'} , City:,~DlJ f\L State: 'tDf ~ Value oC~o(~~VJ/Pellet Stove/Insert: f\ i r) ) ( lease clrc~e appropriate appliance) 1--- VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth S,treet Springfield, Oregon 97477 ~""Hlrn.."'IIt;.LU Office: 726-3759 INSPECTION LINE: 726-3769 m40() Phone #: .\~ 10- (J)I.oC{ Zip: Ql4li ..... reliminary Inspectio is $15.00 (prior to installati~n of insert) od Stove/Pell ert Permit. is $15.00 + $ .75 state surcharge + $10.00 Issuance. Type of Inspection ~uested: Contractor: ~ -------- Address: C' ~ lty: State: Construction Contractors Registration #: - Expires: By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was provided with the Yood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the wall covering may be required to be removed. V>rn If h J~' e i""t#ture - (1)71" 1 ;-fuJ. / fJ FOR OFFICE USE REQUIRED INSPECTION(S): YOODSTOVE/PELLET/INSERT Date of Application: Y/.~/5' L Total Amount,Collected: / ~~.~ Receipt #: .C:::;'74~ Issued By: Checked for Delinquencies: ' ~ Job #: 1!J3// ~ /9 ? Date I' 7- PRELIMINARY ~. 92//,'?7 AfJ~ Checked for Historical Status: ~ . I I --- . ( \ .1 1,