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HomeMy WebLinkAboutPermit Mechanical 1996-3-4 i' '" , STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 .... Job Location: 7L:J'77 ~.ffi~L/A ~ . / Map #: //' ~ '2 -'5t5' - 3 ? . ~ M4~ -~~,-:/,~~ ~?2 ~U/#-~. ,. .;.. -/ State:~;:r. ,. Assessors Tax Lo t #: tt:!?S-/~ O\Jnel- : Address: -~,(' ?o//-372? Phone: #: /~/-"'?2.// 5~- Value of \,Iood Stov~enet St'ove/Inse~ /)~ c:ri!F City: Zip Code: ~?Y'?~ Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative fee + $10.00 issuance = $26.20 total Type of Inspection Requested: contractor:bC U~~~r' -,MP L'/~?/r~$(7f- Address: 70. 2)~x "< 3~ "~ ~~ State: - , '/ Construction Contractors Phone'#: ~5/-3.7'5"S-- 97Y02- ' 9/5-97 City: ~. Registration #: 7~~~ Expires: Zip Gode: By signing this permi t/application, I agree to call for inspection(s) as required (726-376~). I state that all the information on this permit/ap~lication is correct and tha t I \Jas provided ",i th the \,Iood Stove Safety information for ",ood 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 Quali ty or the Federal Environnlcntal 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 \JaIl covering may be required to be removed. Signa tm-e Date --------------------------------------------------------------------------------------- ----------------~---------------------------------------------------------------------- FOR OFFICE USE REQUIRED INSPECTION(S): \,IOODSTOV~LET/INS~' ~ PRELIMINARY ,~/ t'~6.l> #: ~~2-=7 / Date of Application: "'- y-% Total Amount Collected: ::;2&;- "'2~ Job Receipt #: ~~~;r Issued By, 4 ~ Chccked'for Historical Status: '-Checked for Deliquencies: