HomeMy WebLinkAboutPermit Mechanical 1991-12-6
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
;.- "i
225 Fifth Street
Springfield, Oregon 97477
'Office: 726~3759
INSPECTION LINE: 726-3769
Job Location: 4/?5 L,#~t:EL" /# Sr-
Assessors Mal; #: /7-~.2""~2.., '"=i"~
Owner: 5~VE' /5G-'~L~~
/'
Address: 74~ ,...
, ,
Ci ty: 5p,;=:e-{;::> State: c:::::>,7-? .
Tax Lot #: ~3-?'--~
Phone # : -;t.J / - 7B~
Zip:a?o/;>g
Value of 'Wood Stove(P-e"11et StovelInser~ ~ /~. .,..d!>
(please circle appropriate 'appliance) ,
_Preliminary Inspection is S15.00 (prior to installation of insert)_
'Wood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection Requested: ,?J?E~5"Ji!!>~'?CZL'c/ '~y
Contractor: ,J(~7/tP##L .,ttjreCi< ~;9~~/~ ~r- ~c::;/r:--</c-
'Address: ,7>.0, ,t:?~~ -::2,,~ / Phone #: tb.&3.5::<./~
City: CC-:z:;~-e::- State: ~?+, Zip: q'/C/eJ;;>2..
Construction Contractors Registration #: (/'h::;;-~ Expires: /L? -~-5J'::z...
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 t e testing approval number tp the inspector at the time of inspection. I
also unde s andj;that~f am requesting a prellminary insp~ction, the wall covering
may be r ,'red to e oved. ' .
, . / ... ~ /eJ-06 -,9/
Signature ' CJ Date
FOR OFFICE USE
REQUIRED INSPECTION(S}: Y06DSTOVE~LEi/INSERJE> ~
PRELIMINARY
y
Date of Application: /?-~-~;;;V'
Total Amount Collected: ,~. :>:;;-
Job #:
9//715'-::5
Receipt#: c;Jo, 27/
Issued By:
~~~
-tY/
Checked for Historical Status:
Checked for Delinquencies: