HomeMy WebLinkAboutPermit Miscellaneous 1992-8-25
SPRINGFIELD
YOOD 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 D81:~- ~Lt~
Assessors ap I: \i [)~? 1\11
Ovner: ( Ii J ( ") (a. n 00 ,Do v'/
City: ~~ State: /W Q j){m ) Zip: C{lj-78
Value of Yood Stove/ ~ t StoveeInse~? ~<~~
(please circle appropriate a~ce)
Tax Lot
I: OD\ \~
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Perm~t' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection Requested: \ Jf\ [)2ffi
Contractor: Grr-r\ \~")Q,n\LJ -
Address: _ nV ~~ .\'\'{) t' f\ Sl.~QOj- Phone I:
City: ~-J~ . State:;: Z\llQ (\{JtvZip: C{l4-~
Construction coJactors Registration 1:-&.b--r4::\CJ Expires: R.(l(() ,q().J
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 vas provided vith 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~n .rstand that if I am requesting a preliminary inspection, the vall covering
may b req ire~ to be~v~d.
/~-tit~ (j~ ?~s-h~
s/na~ j
~ INSPECTION(S): YOODSTOVE/PELLET/~~RT) ~
Date of Application: 8 -c9S ,q{J . JOb'l:
, ---
Total Amount.Collecte~: ~. fj~ ~
Receipt 1:.JtJ() (U . Iss~ed By: ()<) rM_)
~ Checked for Historical
(-
Date
/
FOR OFFICE USE
PRELIMINARY
g~I{)~ 1
Checked for Delinquencies:
,r-'
Sta~
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Permit No: qQID-~1 . ~ -'" _rf)
Address: I 0 ~4 \'rn CLUJ:....X.
Issued b~~ j ~: A4sq~L
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.~
2.1~1
l
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 before or upo~ completion. Q
My general contractor i~ M l~~ Go h -"
Contractor registration number [) Lo'f4.. ~
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 Prope ners about Construction Responsibilities on the
reverse of this form.
/k~~'
D~ '/ 'l
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COpy TO APPLICANT
INFOIIATION NOTICE TO PROPERTY !NERS
ABOUT CONSTRUCTION RESPONSIBILITIES
A -.:..
NOTE: , This In.formation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701.055(5),
passed by the 1~8~ Oregon Legislature,
','
f ,
. . '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 persons 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 f'!1ust 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 worker~' compensatiqn 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 must withhold federal income tax from employees' wages.
You will be liable for the tax payr:nent 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 CONCE~N:
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
code requirements that may be broughUo your attention through inspections.
Liability and Properly Damage Insurance: Contact your insurance 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.
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