HomeMy WebLinkAboutPermit Building 1994-2-7
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VOOD 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:
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It{x Lot #:
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Assessors Hap #: \"1 n:2... I c; () ()
Owner: ~~M~ro. fur'.J!..,/-J:f"J
Address: ::lk I W -P r, rIJ '^^~rL l.v,/'..(~Phone #:...::J..!:Ii _ ("CU,,?"'"
City:-4.pv',vv_.'i2,',f..J'g, _ State: ()6J Zip: CJjl../')-"')
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Value of Vood Stove/~llet Stov(l Inser. -'P Ic::.O() .
(please circle appropriate app lance)
Preliminary ,Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75 state surcharge.
Type of Inspection Requested: OR j; .P,t j (}v,-QP~/ t..
Contractor: ('Auf; -l-, Sto~
Address: \\).0 ,'?-,"" :l'-l'11 C> Phone #: L<x7<.. -2,';)J()
City: C(J..A~.I",^1J State:
Construction Contractors Registration #:
OR
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Zip:
Expires:
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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 Vood 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.
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Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE~ET/INS~ ~
Date of Application: ~h \ Cl L.i Job #:
Total Amount Collected: ~ ~c, IS-
PRELIMINARY
VlLJOI;:)c:..,
Receipt #: I \S~{"
Issued By:
ap,
Checked for Delinquencies:
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Checked for Historical Status: ~
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Permit No:
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:;)10 I kJ..Po r>PVv1A1Y--.d &~ fJ,f
E:)~ Date: d-/,/CJ'-I
Address:
Issued by:
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 in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 3B:
. -
1,
~
I own, reside in, or will reside in the completed structure.
2. I
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
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3. A, I _ Y I My general contractor i"
Contractor registration number
LJ I~ <..nc...
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.
A (\(..:v..;,,-~~,~. ~lf.<tl
Signa~re of ~It APpTicant I
~
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
.
. .
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBiliTIES
'.
NOTE: This Information Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1989 Oregon Legislature,
" you are acting as your own contractor to construct a new home or make a substantial improvament to an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern.
~MPLOVER RtES!'l'ONS!31]lIT~o:S:
If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvemsnt of a residential structure, you will, in most instances. be ruled to be an
"employer" and ills peop:e you hire \"Jill be "employses", As the employer, you must comply \"/iththe follolVing:
Oregon's Withholding Tall Law: As an employer, you must withhold income ia:tes from employee wages at
ihe 'lime employees are paid, You will be liable for the tax payments even if you don'! actually withhold the
tall from your employees, For more information, call the Oregon Department of i-leve'1ue at 378-3390.
Unemployment Insurance Tal(: 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 DH::l
at 378.3224,
Worl<ers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation
La~V, and must obtain lI'Jorl(ers' 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 or,c of your
employees is injured on the job, For mers information. call the Workers' Compensation Division DIF at 373.7434,
U,S, Internal Revenue Service: As an employer, you must withhold federal income tall from employees' wages,
You wiilbe liable for the tall payment sven if you didn't actually wilhhold the tall, For more information. call
the Internal Revenue Service at 221,3960,
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Code Compliance: As the ;Jarmit holcisr for this project. you are responsible for resolving any failure to meet
code requlremsnts that may be brought to your attention through inspsctions,
liabilitY and Properly Damage Insurance: Contact your insurance agent to see if you have adequate insurance
covera.gefor 'acCldents -andomissions such as falling tools, paint overspray, waler damage from pipe punc.
tures, iire, or work that must be re-done,
Time t~ SUfJ(3,rvise Em;Jloyess: iIt1a:<e sure you have sufficient time to supervise your employees,
ElIpertise: Make sure you have the ellpertise 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