HomeMy WebLinkAboutPermit Mechanical 1997-7-18
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UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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Job Location:2Z 90 _ i~t.J;!...1 (fJ-.4VI
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Ovner:, ' (11o')e{o~ kAJCH
Add ress ~ 2.<- 9 (JLA{),'~p.. · I AJAl.{ ~
Ci ty: D Spl2../(;4J=iA...L ";tate: (')/1
Value of IJood StoveB Stove~'1:frz.L/~/~
Preliminary Inspection is $15.00 (prior 'to installation of i~ert)
Uood Stove/Pellet/Insert Permit is $15.00 + $.75 state su~t~e + $.45 administrative
fee + $10.00 issuance = 526.20 total ' ~~~ ~O
Type of Inspej)ion Requested: .r;";IIYJo\ y, )"~J,N
Contractor:'& PH U l.:,. "dSJfr7f ('~}-,~~,~ ~~ ()
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Address: S'),' u.]1l ~..v ~ ...('\~ _<.~~ _$"~~ _,C:J~ Phone #:~,R''l.- OQ/1
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City: C\Jc-.f=~\r-:= Stat~'f ~ ~ .r<t,<V ...<<,~(j Zip Code: 07t./D<..
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Construction Contractors Registration ~~O~I Expires: 1'-:/97
By signing this permi t/application, I' a~ee to call for inspection(s) as required
(726-3769). I state that all the info~mation on this permit/application is correct
and that I was provided with the UoodStove 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 I am requesting a preliminary inspection, the wall covering
may be required to be removed.
Tax Lot #:
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Phone: #:
7t/ C::, - 70 3 ~
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Zip Code:
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Sigriatute /
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Date I
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FOR OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE~/I~
Date of Application: ~. \ ~ .C\...~ '
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Total Amount collected:
Receipt #: ~\~~\
~RELIMINARY ~
Job #: O/\\t)'Q 0
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Issued By: \."(\\fJo)
Checked for Deliquencies:
Checked for Historical Status: