HomeMy WebLinkAboutMiscellaneous Application 1993-4-5
SPRINGFIELD
1
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: ~?J3~ \_ ~)(\ t-N)) .\\. \\G\
Assessors Map #:I~l)r3?l~ . ~Tax Lot #: nI3(Y)
owner\_~:k_r..Q.) ~)~ ~0.. .
Address: .~~3~\ ffifNA-tt-\\q Phond: (~\-lo'KX1
City:&J\Jf\ ~.n~o_. statl\ (9\t~Pfr'\ Zip: ~'rj~
Value ~Stove ~~ t Stove/Insert:. p~ ..
(plea~~ ~. aJ~ priate appliance)
Preliminary Inspection is $15.00 (prior to installation of
Vood StovelPe11etllnsert permi~ is $15.po + $10,00 Issua,c,
Type of Inspection ReqUest~J\ 00 ~n \
Contractor:~ . ~ ~-ASn}(Clfdo
Address: B\' ~ ( nSJ) 0J/QO~f)0
Ci ty: \Jv! ~- - State: 0JJ\' Q
Construction Contractor~. Registration #: (~~ / R~
insert)
+. $.15 st te surcharge.
Phone
#:t\-"l_C)'ffi-~
Zip: S1f\~?l \
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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 Wood 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 remov
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v- S- -'73
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): ~~PELLET/INSER~~
Date of Application: 4-=- C)-czs ~Ob #:
Total Amount COllected:~,,~ ,I) S
Receipt #: ~ Issued By
Checked for Delinquencies:
PRELIMINARY.
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Historical Status:
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Issued
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, J DJ 1 Date: _ .:1~
Permit No:
Address:
FOR 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
underORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
,Fill in the applicable blanks, and initial boxes 1 and 2, and either .box 3A or 3B:
WI
1 .
2. I ~
I.own, reside in, or will reside in the completed structure.
3. A.
I understand that I must. register as a construction contractor if the structure is sold
or offered. for sale hefore or upon cdelion. . ~
My general contractor is ~ . 0 _~ )
. r-?L'/
Contractor registration. number ~. ~
1
I will instructmygeneral contractor that all subcontractors who work on the struc~
ture must be registered with the Construction Contractors Board.
OR
3. 8.1
I I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with theConstruc-
tion Contractors Board. If I change my mind and do hire a general contractor, I will
contract with a contractor who is registerea 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 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.
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Signature of Permit Applicant
1(,5'- 93
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT. FILE
PINK COpy TO APPLICANT
..
INFORMATION NOTICE TO PROPERTY OI~RS
ABOUT CONSTRUCTION RESPONSIBILITIES
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NOTE: Thisjnforl'lJation Notice.to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with OAS 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.
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IEM~lOVIE~ ~IES~Ou\%~~~~Ulr~IE5):
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
/ - - , .
in the construction or improvem.ent of a residenti~1 structure, you will, in most instances, be ruled to be an
"employer" and the peopl~ you hire will be "employees". As the employer,' you m~st comply with the fOllowing:
Oregon's Withholding Tax Law: As an employer, you must withhold income taxe~ 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 em'ployer, you are required to pay a tax for 'unemployment insurance
purposes on the wages of all employees: For more information, cat! 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 obt~in 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 Wo~kers' Compensation Division OIF 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 ev~n if you didn't actually withhold the tax. For more information, call
the Internal Revenue Service at 221-3960. . .
OTIliIEIRl ~lESPONS~BOUlrOfES AlMD AREAS OF CONC~AN:
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Code Compliance: As the permit holder for this project, you are responsible tor resolving any failure to meet
code requirements that may be brought to your attention through ,inspections.
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Liability and Property Damage Insurance: Contact your insura~ce agent to see if you 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.
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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 S1. NE, Suite 300
Salem, OR'97310-0151
Phone 503-378-4621
0244J 10/24/89
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