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HomeMy WebLinkAboutPermit Mechanical 1996-9-27 . . .... ~-~~I ,.. " " ( \f~ D~ v\:Al0 .... ..'w..... UOOD STOVE/INSERT INSPECTION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE; 726-3769 ..... ,,:- ,"~' '. Job Location: ~t:('-I-'~ C!....4~\ 1/U,4G AsseSSOl-S Map ~: \~O:?2/L' L- ELm8c rV,OLn-rJD Address: rS9-~ CfitL]) J /JA'0 fA) A-tf Ci ty ; ~f.t../Ax::r ;:.-/ e.. LT'\ S ta t e : ?JoL- co / S{yv I ;)A-^-( ~";~:;~'"'. " Tax Lo t II: "- {)~qCXJ ,- Ovner: Phone: #: 7f~-3!3Y 97 L/-7 7 Zip Code: Value of Vood Stove/Pellet Stove/Insert: .r Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.Q5 administrative fee + $10.00 issuance: $26.20 total Type of Inspection Requested: U-f e...cI' ~/..e:f J>fJ tie /l1.Sh,tlvd? ~ Contractor: 'G-o~ (-))~ 1l1e+-a) '..fJr-o~ ~ -!--1vC---/ ' Address: ~d-~ 111 ~,0 ~<;/ Phone.~: ,/jt)~ -~ ~J-./ City:_S;Jt2ltOlfF/~D State: ()~ Zip Gode:Q7cL"rJp Construe tion Con trac tors Registration #: ;Jt-, '743 Expires: J7"9 '7 / I I ' / 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 that I ",as. provided ",i th the \.Tood Stove Safety information for ",ood burning appliances and preliminary inspec t ion standards. I further s ta te tha t the appliance I am installing meets smoke emission standards as set by th.e" Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to 'pr.ovide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the ",all covering ay :-eqUire~t~Q:w~ 9ft7/7~ 19natul-~ - 0 Date . J ===========================~=====~=====~============================~================== . OR OFfICE USE~ REQUIRED Date of Application: .Qj _ .C\\p Job Total Amount Collected: ~.OO Receipt ff:A~X\ PR71IMINARY U: ~\QrO\\ Issued DY:~~ '-Checked for Deliquencies: j Chccked.[oriiistorical Status:".-