HomeMy WebLinkAboutPermit Mechanical 1999-11-22
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: l 'i &D S. <:(,)(C.oo~y~
Assessors Map #: 11 6 3> :3 Lf Lf 3
Tax Lot#: Db 1(1)
Owner:
~ do... +H 1._,Q_tJ.,) 4M r' ({ rt <1..(
Address: f cf (p()) -:S~l~c..-y~
City Yi
Value of Wood StovelPellet Stove/Insert:
Phone#:
7tfCf-z..?5to
Zip: 9 trt () 5'
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l ~-JCE:
Preliminary Inspection is $15.00 (prior to installIlrt!~ ~lGfilM{f SHALL EXPIRE IFTHEWORK
Wood StovelPellet/lnsert Permit is $15.00 + l.oOOilttOE}J~tJNmeAJt:flIrS1PERiWTsNotIO.OO
Issuance. COMMENCED OR ISABANDONEO FOR
T 1\TTf'7Il\ITI()th"OR-o:>rt"r.t'~d'~1 ,8aUlrG~ "cu,tcANY 180 DAY PERIOD
ype 0 - nspec IOneques e:. J. . . .
follow rUles adopted by the vregon UHlIIY
G6I1Waa~~t;m Centr:fJVV)'NJ.i-'/;e8 d~'e set forth
in OAR 9:::>~-lIv'j -UU1l" mrougrr U.M'-"'!-1::>t::.-uu 1-
~98'Pes~ou may oblairi Gopie;: of u~, mles by
calling me cameL ~!\iOT.E:.m8 H~I€pnOm~
Ci'iY_1mberforthe Oregon Utiihy NotificaS~t6:
t;enti,;,' 15 'i "~~\jIJ-;:!~i;N;:j44'.
Construction Contractors Registration#:
State:
(please circle appropriate appliance)
Phone#:
Zip:
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 Wood 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 n,umber to the inspector at the time of inspection. I also understand that if I inn requesting a
preliminary inspection, the wall covering may be required to be removed.
cry;10fA IA/!e P ~ ~ Jl,} 2t) 91
Signature ( /'-/ \ ~
FOR OFFICE USE
REQUIRED INSPECTION(S): WOODSTOVEIPELLETIINSERT
Date of Application: 1/ P 2..-( tf 'I Job #:
I .
2-' -'S1>
Total Amount Collected:
PRELIMINARY
qtfl S fo
Receipt #: O? {; 2 tf f
Issued By:
'cd tJ ~
Checked for Delinquencies:
Checked for Historical Status: