HomeMy WebLinkAboutPermit Mechanical 1993-9-30
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Or~gon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: L-J~Sls As-t~",)
Assessors Map #: \ } O:J ~ "). ~Lj Tax Lot #: CJOfaO I
Owner: ~t'~ ~ j p.i,ry-..r~J
Address: Y~CXc::. dD.,f1j\) Phone #: J;:ll...-')lLt()/~
CitY:_4-rV\\r\(j~'iP;JQ State:nR ,Zip: C1jLf7>?
Value of Yood Stove/Pellet St~ve/Insert: .:tJ 140000
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $IO.OO Issuance +$.75 state surcharge.
Type of Inspection Requested:
~&\L
P p. ^,yf":-f P9v> -r^^OA.-cJ
Addres". / 0 j.( I r- V\ ecr Ln () p
Ci ty: , TAA d~ State:
Construction Contractors Registration #:
Contractor:
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7 oc) fry 0
Phone #: '3 Lf 5 ~ 'gCSb
,zip: C(l LfO )
Expires: I J ~ ) qL(
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this applicationlpermi t 'is correct and'
that I was provided with the Yood Stove' Safety information, for wood burning
appliances and preliminary inspection standards. I further state that, the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality 6r t6e,Federal Environmental, Protection Agency 'and I agree to
pr,ovide the testing approval"'number to the inspector at the ~ime of inspection. I
also understand that if I am r~questing a preliminary inspection, the,wall covering
m~y Jo/ 7Uired. to be removed ~':' "
\17I.t!..,;/~~~ q holq...,
~ignature ~ Date
, FOR OFFICE USE
REQUIRED INSPECTION (S) : ~I PELLErQ,giSERV .:A--' PRELIMINARY
Date of Application: '1/?::>f)\q" Job #: Cj~) ILI/'
Total Amount Collected: ~ S 'j S
Recei p't #:
I bYLf:2.
Issued By:
Q6,
C6ecked for Delinquencies: ,X- '
Checked for Historical Status: A-
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Permit No:
C]~))LfI
L.J ~ ~ s Asl.e.J\)
aB. Date: q /'?>oI Q3
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. y.j I own, reside in, or will reside in the completed structure.
*"
2.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
3. A.I
I My general contractor is
Contractor registration number
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
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3. B. I X I I will be my own general contractor.
,
If f 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 sid of his form.
Q/3()[li'3
Date
CONSTRUCTION CONTRACTORS BOARD
0244J 8/91
WHITE COPY TO ISSUING AGENCY PERMIT FILE
PINK COPY TO APPLICANT
n
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INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTF;:: _ ,Thislnformati9n 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. . '
If you are acting as your own contractorfo construct a new home or make a substantial improvement to an
, existing structure, y'ou can prev~nt many problems by being aware of the following responsibilities and areas
of concern. - ' . ,', '
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EMPLOYER RESPONSIBILITIES:
, "
If you hire persons no~ registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction ot improveme'nt of a residential'structure, you will, in most instances, be ruled to be an
"employer" and the people you hire will b~ 'iempIOyees".. As the ,employer, you must'com~ly ~ith'the following:
'Oregon's Withholding Tax law:. As an empldyer, you rTlust 'wit,hhold income taxes from employee wages at
the time employees' ar~ pai,d. You will be liable fqr the. tax.payments 'even if you don't a<?~ually withhold the
tax from your employees. For more information, call the Oregon Dep~rtl1)ent 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. ForfDoreinformation, call the Oregon Employment Division DHR
at 378-32,24.
I.
Workers'Compensation Insurance: As anemployerj' you are subjectto the Oregon Workers' Compensation
Law, and must obtain workers' 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 one of your
employees is injured on the job. For more information, call the Workers' Compen.s~tion Division DIF at 373-7434.
, '
U.S. Internal Revenue Service: As an employ~r, you must withhold fed~ral incomet~x from employees' wages.
You will be liable for the tax pay,:"ent even if yo,u didn't actually withhold the tax. For more information, call
the Internal Revenue Service' at 221'-3960. .
OTHER RESPONSIB!lITIES AND AREAS OF CONCERN: ,
Code CompJjance:As,the permit holder forthis project,'You are responsible for resolving any failure to meet
code requirements that may be brought to your. attention through inspections. '
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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 so they can perform
the required inspections.
If you have additional questions, write to:
Construction Contractors Board
700 Summer St. NEt Suite 300
, Salem, '0R'97310~0151 ' ,
Phone 503-378-4621
0244J 10/24/89
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