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Home My WebLink AboutPermit Miscellaneous 1992-12-16 ~ SPRINGFIELD ~OOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: 5// /) u/ffs C( ~I- ~ Assessors Map #: \ ~ ()a~~?J?l ..- - Owner: .7'0t0rt-LJ \), tR r)J I (V_~ Address:S /I? ()~ J'S'Y Sf,.. Ci ty: S;P,{'//vq~ e..(d/ State: c:t:e , Value of Yood Stove~elle~ Stove~;e~ (please circle appropriate appliance) - S,1//, /!J.q -0 "e, () () rc ~ . Ta: Lot #: () PI Q . Phone & It . (,Vork.. # : '/ f/ /,.- .5 ? 69... ?{/6 --6 S-:ss.-- Zip: 9?V?p b2.P-. 00 r Vo Preliminary.Inspection is $15.00 (prior to installation. of insert) :OOd S :o:~pel::::I:::::s :::i~;~ ~$~~ +~ltJ~ ~r~s;F~e + ~;; surcharge. Ii WILl t:Y( . . ~tontracto ',_- -p'J ~f;:J7t/S// .'--' -1(< ~ne #. ~-4J6~ ate: iJit A;: 4'~/ , ~:' .6, / ../ 2~ 7, ,/ EXPl'€.e;s'E/1: ,. ~ v '/ Construction Contractors Registration ~ ~2ppl~ l ~ ~ 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 may be required to be removed. '/Sig!J~~,~ . Ci ty: /d-/b -- 9;{ Date FOR OFFICE USE Date of Application: YbODSTOVE~ELLET/I~~ ><: '( n .-"'" . 12//~/?A/' Job #: I '''I ,- 4rJ 7S'" ( - PRELIMINARY -~ / 9~/7/7 REQUIRED INSPECTION(S): Total Amount Collected: Receipt #: "'7 L/ t[; cf Issued By: /~ .. Checked for Delinquencies: --- Checked for Historical Status: \Iff'- .\......"- e e ,. . permifNo:9z/"1 / 7 , Addless: c; //7 . ZYffr. <; r: Issued by: ~ Date: 12//&/92- . , <I!'- \ , FOR OFFICE USE ONLY . STATEMENT: .INFORMATION NOTICE TO PROPERTY OWNERS , " ABOUT.CONSTRUCTION RESPONSIBILITIES .., , '1 < I '. Note: Oregon'Law; ORS 701;055(4) ,'requires. residentiaI90nstructior1"permit' applicants who are not r.egistered with the Construction Contractors Board to sign the following statement before.the b'unding permitcan be issued. This'state- ment is required for residential building, electrical; mechanical, and plumbing . permits: Licensed Architect and Engineer applicants, exempt from registration . .underORS 701.010(7)" n~edn"Otsubmitthis statement. This statement will be , filed withthe permit. . Fill in the applicable blanks, and .initial boxes 1 and 2, and either box 3A or 3B: . .' ". . . . , . 1: ~I.:.." 'Iow'n, reside in;:onivill reside (n the completed structure.' ,,' ,2. ~'.:.Iunderstand that:! must register.as'a construction contractor if the. structure is sold '.: --:. ; or offered forsaleb13fore.or upon completion. .: ,... .... ..... .......: '. . 3.. A.I. .: ," " "' ~ . . . . . . . I. Mygeneral"contr.actor is : ." . . , '. . . Contractor registration number '. I:.~ill.instruct niy'ge'~~r~l:co'ntract~r that'ail ~ubcontractors who work' ~:)n the struc- . . ture mu'st -be registe'red with the Construction Contractors Board. . . '. ." . " . OR 3. B. I~I' J will be my own general contractor.... .' ,. --- " . . :' '. : If I'hire subcontractors, I will hire only subcontractors registered with the Construc~ tion Contractors Board. Itlchange: 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 t~is 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 ~m the" reverse side of this form. 'f\~ ~,. Signature of Permit Applicant . . ".' I '. _'. /~ -/6 -c;~ Date '. . ,. , . ,1 ... :". ',.,' " ~. .'. . ..... :\...., .' '. . :."'.': . ; . " . .;. ,l-. ~ ........;' ,:. " : . ',:'. ~ '. .: ~ CONSTRUCTION/tONTRACTORS:BOARD . ,.~. 0244J 8/91 .'~,' ..( ~:;.:. ;:". :........- . ", ........\.,... :',. .:..,' 'n . . ':'.J ~ .'. It.... > ~_ .", " .. '. ","" ;; , WHITE COPY TO ISSUING AGENCV.,F;?ERMIT;F.JILE PINK COPY TO APPLICANT ",'l>>""~" ~ .It" ',-,\ . --'- ",W", .......... I ' e INFORM :nON' NOTICE TO PROPE'RTY OWNERS ABOUT CONSTRUCTION RESPONSIBILITIES NOTE: This Information Notice to Property Owners About Construction Responsibilities was developed by th~ Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature. If 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: If you hire per~ons 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 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 378-3390. Unemployment Insurance Tax: As an employer, '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 DHR at 378-3224. Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must 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 DIF at 373-7434, U.S. Internal Revenue Service: As an employer, you mustwithhold federal income tax from employees' wages. You will be liable for the tax payment even if you didn't actUally withhold the tax.. For more information, call the Internal 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 faiiure to meet code requirements that may be brought to your attention through inspections." Liability and Property Damage Insurance: Contact your insurance agent to see if yoLi have adequate insurance coverage for accidents 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 Employees: Make sure you have sufficient time to supervise your employees. Expertise:, Make sure you have the exper~ise 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. ' , ,; , . , ". .,Construction Contractors Board 700 Summer ,St. NE, Suite 300 Salem, OR 97310-0151 " ' , :, Phone 503-378-4621 " If you have additional questions, write to: . . : .' ~ ~. '0244.1 10/24/89 . .':: ,}: ~ ~ . :