HomeMy WebLinkAboutMiscellaneous Application 1990-1-2
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SPRINGFIELD
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: L\-C\6C\ \:J(\~U ~:Xe~
Assessors Map #: y,\ Dd~3~? \J
Owner:, \\ ffi)\C\ > _ ~~ '\JI V
~ ~~\(\ ~\~\ \ st.,
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Tax Lot
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Phone #: ~\0-4ry),o.
_ Zip: C\l118
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Stove! s t: ~ c'.
"T'C" e appropriate appliance)
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspec~ion Requested:\ l~.,~l~ <1 ~ \~
Contractor: ~Ch Q~
Address:
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Phone #:
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City:
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State:
Zip:
Construction Contractors Registration #:
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Expires:
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By signing this permit/application, I agree to call for an inspection(s) as
required (726-3769). I also state that all information on this application/
permit is correct and that I was provided with the Wood Stove Safety information
. for woo:zrning appliances and preliminary inspection standards.
J~~fu'r.e ? 1<- /)1e-~rr &;;1- 9.0
I' FOR OFF ICE USE
REQUIRED INSPECTION(S): ~OD srn~~INSERT
(-2 on ~{,7-l~' ( P \
Date of Application: . -\ '" Job #: c:::- :';', 1'- ~.t::-~"
Receipt #: J ~ (0 '1~ Issued ~y." LD~J
Checked for Delinquencies: ~ Checked for Historical Status: ~
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PRELIMINARY
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Permit No: m 1m I - .
Address:4qC\~ Dc\. t D\)<_ '
,Issued by: ~8rfi. ~ate:Li~O
" .' - 'STATEMENT:
INFORMATION NOTICE.TO PROPERTY OWNERS
ABOUT. CONSTRUCTION RESPONSIBILITIES.
Note: dregon Law, ORS701.055(4), requires residential building permit applicants
who are not . registered with the Construction Contractors Board., to sign. the.
following statement before the building permit can be issued. Licensed.Arc'hitect .
and Engineer applicants, exempt from registration underORS 701.010(7), need
not submit this'statement. This statement will be filed with the permit.
. Fill in, the applicable blanks, and initial box 1. and either box 2A or 2B:
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1., I_/{
I own, reside in, or will reside in the completed structure.
My general contractor is
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2. A. I
Contractor' registration number
I will instruct my general contractor thatalls,ubcontractors who work on
the structure must be registered with the Construction Contr~ctors Board.
OR
B. L!/ l 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 00 hire a Qeneral
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.
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I hereby certify thatthe 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. .
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Signature of PermifApplican,
1-'"]- 7tJ
Date
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CONSTRUCTION CONTRACTORS'BOARD '. .,
0244J 10/24/89 . ,':' '
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, .' WHITE .COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT,
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