HomeMy WebLinkAboutPermit Mechanical 1990-4-27
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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: 2-Li62- .\2a(/\rh \)v-
Assessors Map #: 17 0 3 ~L/ Lf 3
Owner :Im vS ~,i), me'. tv.. 11/')( ~
Address: 2A S Z- J2-a,V\r~ 1) r:
City: ~~ State:
Value of voo~ ~ve/pellet Stove/Insert:
(please circle appropriate appliance)
Tax Lot #: (j L.j 7j) ()
_Phone #: I l.f 7 - 7 rl9 /
J}U , Zip: q1~l- (
~ \4flC\ 9
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection ReqUested:~ ~\-a ~
Contractor:_0f)\\sc1mc1tQr\}, ~ ~ ~~
Address: UJ() ~_ l\C) Q -. Phone #:
City:. J~?k( ,('\l State: \ Pf ./
constr~cti~n ~o\J~actors Registration #: (5 fl5''312
Zip: C11411
Expires: ~/-24f-q()
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 also understand that
if I am requesting a preliminary inspection, the wall covering may be required
to be removed.
}r:AA $1 ct:J.Ilz~t.Ld~/ 1/ - ~ 1- f 0
S1 na tur Da te
FOR OFFICE USE
REQUIRED INSPECTION(S): ~ODSTOV~LLET/INSERT ~
4. IL') . C\n Job #:
Total Amount Collected: \. ~.ry:::) rl .
Receipt #: J (j) ~ (P Z-- Issued By: '-'2Ji ~
Checked for Delinquencies: _____ Checked for Historical Status: ~
Date of Application:
PRELIMINARY
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Permit No: QD03lJ( ~A }
Address: H 1~~~OJ\0 J \J
Issued by' ())!l.JJ.-) Date: 4/ ;7..-11
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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, LJ::::::1 I own, reside in, or will resid~V~the compl~e;!.(j>t~S!~HeI\ h I ~ '
2, A, ~My general contractor is \_ ()'ISf) leX J fH..v-c \L'-J\Dlf<~
Contractor registration number ~ ') \.~0
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,
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.
1; ~" tj,-r;:)_, 7;;Vt),~ff,,'/f/
,Slgnatu!;8of Permit A"pplicant
, If - 1. }-( ~ '1 /)
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 10/24189
~py TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
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