HomeMy WebLinkAboutPermit Mechanical 1995-10-26
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UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 7040 &fnP_/h~ 8-1
Assessors Map #: 1?-o.::?.-.~'!5''' ~ '"3
O~ner: ~,I'-O / !AkJl/h.jer-
Address: -2.f2YD ~#J1,,/I/;/A" ,"Y.-/-
Ci ty: -}LJfr( State: ~f- Zip Code: ,
Value of Vood Stove/Pellet Stove/Insert:fI:! 5c;.~
prelimina~'~nspection is' $15.00 (prior to in~ta~lation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
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Tax Lot #:
&'~/~~
Phone: #:
'k2b- 0922-
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$.45 administrativJ
Type of Inspection Requested:
contl-actor:Mj ~ ~"./~:P
Address: r;]8flt/~ l1h~~' (),f-
Ci ty: ,<:';/J:/2/ State: &~
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Construction Contractors Registration #: ~~(?~~
Phone #: rf6-' 5665
Zip C,ode: 97C/"? r
Expires: ,7- 7'h
By signing this permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and tha t 'I ~as provided wi th 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 Prot~ction 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 r:uir1 t~b~ ;;veLd.
sJA1iJ t!~ y . Date //J- e2b -7'5
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/f'.~/Y ?~rE' 1 FOR OFFICE USE
REQUIRED INSPECTION(S):~PELLET/INSERT ,~
Date of Application: /P-7/'~;;-
C//. ;2 t;::>
PRELIMINARY
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Job #:
Total Amount Collected:
Checked for Deliquencies:
Checked
Issued By: ~~ /' .~
for Historical,Status:
Receipt
#: /",y~
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