HomeMy WebLinkAboutPermit Mechanical 1990-10-19
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SPRINGFIELD
1I00D 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\ ~ 0 ..b~rn-t?-, 6l 0 \f\ Dll.LX) _
Assess~rf Hap 1I: . \lI/O?1~fJ ~4 Tax Lot 1I: nE;(o(X)
Owner: N (\ c:y \VD.'\\ ~
Address: .Y\~ 0 - ~ili~ ") ~ [\, Phone 1I:
City: ~ ~ ~ G rfJ State:., (\ill 20' Zip: Lt.l41,
Value 0{1I'b~l&0/P~~ ~tove/Insert: ~lll?{) p
(please circle appropriate appliance)
preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + .....state surcharge + $10.00 Issuance
Type of Inspection ReqUested:~()()~ ~~
contractor:~~ l ')~~ ~
Address:
Phone 1I:
City:
State:
Registration 1I: Al Q~L\ ~
Zip:
EXPires:-B!tl(O / ~
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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 1I00d Stove Safety information for wood burning
appliances and preliminary inspection standards. I also understand that if I am
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gnature v. 0 Dafe
FOR OFFICE USE
Construction Contractors
REQUIRED INSPECTION(S~ODS~P~:~SERT ~ PRELIMINARY
Date of Application: ((). \L.l' () Job 1I: q()lA'lq
Total Amoun~..6opected: c!) LP . ~ 5 fJ --
Receipt 1I: l()O 104- Issued By: '7::J)(~
Checked for Delinquencies:
Checked for Historical Status:
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.. ~, /100
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Permit No: CfO \~ rr\
Address: fj~( 0 ~JjH;; G Lcur\
Issued by: t7\l j)Q)oate: itf-E/{O
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4), requires residential building permit applicants
who are not registered with the Construction Contractors Board to sign the
following statement before the building permit can be issued. 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 box 1 and either box 2A or 2B:
1. ~ I own, reside in, or will reside in the completed structure. -LA n
2. A. ~y general contractor is . (-1L):;r'~ 000. Q \'\\0 ~
Contractor registration number c!J( (lJ4.....~
I will instruct my general contractor that all subcontractors who work on
the structure must be registered with the Construction Contractors Board.
OR
B. L-J I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors registered with the
Construction Contractors Board. If I change my mind and ao 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.
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I hereby certify that the above information is correct and that I have read and understand
the Informatipn Notice to Property Owners about Construction Responsibilities on the
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VI,Ii"',m of P"~"", D.Io
CONSTRUCTION CONTRACTORS BOARD
0244J 10/24189
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