HomeMy WebLinkAboutPermit Mechanical 1992-10-23
VOOO STOVE/INSERT INSPECTI
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
J6vo
225 Fifth Street
. Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Job Location: r9~~~ ct\ewr1Q 1\ \_~\ .y_r:o~ ~.
Assessor~Map #: l. 0 O,~ \, q~. _ (j " Tax Lot #: CJ:A W
Owner:\' 1 ~ 0 ilJ\ ~~
Address.~ ~'2\~ ~ ~.\Qf) tY \<c".L-phOne #: t\~ ~f)304
City~ .{)~_ 0 State: (QJ2] Zip: q1411 I
Sto~/Pellet Stove/Insert:\J..~~ 150 ~
. ~ appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Per~i ~ is $15.00 + $10.00 Issuance + ~
Type of Ins~tion. ReqUested~~~\(1f\(\ i f\CD /13
Contractor: ,-'1'<\ i\Q P .\ t~_)\ -0\~)- a
Address: (~~\)C\ C-X\\t\ ~\~ .Phone #:
City: f~.tn9..._J State: l~M~ Zip:
Construction C~tractors Registration #: ~/'\()l~ Expires:
state surcharge.
c0-A~ - ft~t t
0140'
QdQ.g3
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 appro number to the inspector at the time of inspection. I
also understand tha 'f I requesting a preliminary inspection, the wall covering
may be required to ved.
~tf5 /tfh, 3/?-?
Da tel
...,. FOR 'OFFICE USE
, . . . '~. , . .'- .
REQUIRED INSPECTION( S) : Gb6DSTOV~~tLE'T /INSERT
Date of Application: tn'KG :q9_
Total Amount Collected: c9'Q'~S~'" _ .
ReceiPt #: \ t?~ C)) Issued By: l ffi)
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Job #:
PRELIMINARY
q Q \4.PJ~
Checked for Delinquencies:
Checked for Historical Status:
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. Permit No.: q A \4Pf7_\ __ ;}n
Address: Q8~/;;:J~()lQfl ,~.
Issued. b~lJ:X1,-_) . DaQ: ID.23g~
FOR OFFICE USE ONLY
ST A TEM ENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
. Note: Oregon Law, ORS 701.055(4), requires residential construction permit
applic'an-ts who. are not regisfered 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 Archi~ect and Engineer applica.nts, exempt from registration
under GRS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
~illlin ~j ~PPI:C:~~ ~~::7'i:n:r i:~:a:e:~;:~n1 t::dc:~:~:e:t::~:t~:e3A or 3B:
2. I I I understand that I must register as a construction contractor if the structure is sold
" '. or offered for sale befo.re ~ upon c~mpletion. .
3. A. C:tz:2J My general contractor IS~ 0 e..- ~~ 1 \'0 tt"5\
T . Co~tractor registration numbe; ~44f"] lo .
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
th Information Notice to Property Owners about Construction Responsibilities on the
revers ide of this form.
fA
ture of Permit Applicant
/.fz}h?
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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INFOh,vdATION NOTICE TO PROPERTY 011lfNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
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NOTE:\ . 'Tmis/inform:ation Notice to Property Owners About Construction Responsibilities
was developed by t~e tonstr.~ction Contractors Board in accordance with ORS 701.055(5)';
passed :by the.. 1989 ,,Oregqn Legislature. .
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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 la~or 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'sWithholding Tax Law: As an employer, you mllst withhold income taxes from employee wages at
the time employees are pq.id. . 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 e.r:nployees. For more information, call the Oregon E;mployment. Division DHR
at 378-3224. -
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Workers' Compensation Insurance: As an employer, yol,J qre subject to the Oregon Workers' Compensation
Law, and must obtain workers' compensation insurance. for your employees. If you fail' to obtain workers'
compensation insLr'rance, you may be subject' to penaltl6sand will be liable for all claim costs if one of your
employees is injured on the job. For more info,rmp,tion, ,call the Workers' Compensation Division DIF at 373-7434.
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U.S. Internal Revenue Service: As an employer, yqu must withh~ld federal income tax from employees' wages.
You will be liable fcirthe tax payment.even if you didn't actually withhold t~e tax. For more information, call
the Internal Revenue Service at 221-396d. .
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
...Iode Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet
l;oder.equirements that ,may be brought to your attention through .inspections.
Liability and Property 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 s() 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
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0244J 10/24/89