HomeMy WebLinkAboutPermit Mechanical 1993-5-3
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YOOD 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: (;, 9 So f? 1 v ~ 15 ~ L l ~
Assessors Hap I: '{ 00A ,,<-:2-/:)0:?' '
Owner: r f ;.r,-fo v J . 0 F c::: L ~ r..........-
Address: 'q~O B r ~J liP 13 C' L L~
. Tax Lot
,""
?~P <"~ g F-r eel
I: r)4A ofY~ -)
- ~
'M 7~
Phone #: 7 <,L--t:,--..s-i.{- 0 ^7
City:
;5 /) '- .; ~ rA ~ 1'&0- /~ .-I
, -
State: 0 fp 9.6 ~'
Zip: 9/ ~ /' l:)
Value of Yood Stove/Pellet Stove/Insert: ~ It{) ~ .
(please circle appropriate appliance)
PreliminaryInspection~is $15.00 (prior to in~tallation of insert)
Vood S t ove/ Pelle t /Inser t Pe rmi ti s $15. 00 + $1 p-~O Issuance + $.75 's tate
Type of Inspection Requeste",d~_\{, \.~ Q ~ ht - ~~-lt)-~
Contractor: A D nQ~U . \J
surcharge.
Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
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 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 understand that if 1 am requesting a prelimin~ry inspection, the wall covering
may be required to be removed.
"""-I n!:rr?LJL;O C;C; Y--C/" . .' . .
" ,.ff-, '. FOR OFFICE USE
Date of Application:' 5.3 < . JOb(l:
Total Amount Collected: .-...f)S .rl~ ,~.
Receipt #: A31'I' -' . Issued By~ffi ./'.
Date
c f{J58Lo
Checked for Delinquencies:
Checked for Historical Status: