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HomeMy WebLinkAboutPermit Mechanical 1999-12-10 WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD COMMUNITY SERVICES DIVISION - BUILDING SAFETY 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 flIlSPECTION LINE: 726-3769 Job Location: /7(P(., CCUVUa...SK.,; Assessors Map#: ,\ l 0 ? '2..C::; ~I I ()j;}{) Owner: ~cf ilJ~ Address: 17 ~ &, CL:UUU-CL.~ City:~JJ Value of Wood StovelPellet Stove/Insert: p~fl(1~ Tax Lot#: fle~ State: ~ I [PI t'/../ Phone#: /C/7--i::f70 I, Zip: Cf7c1'77 (please circle appropriate appliance) Preliminary Inspection is $15.00 (prior to installation of insert) ~-~oci ~ellet/Insert Permit is $15.00 + $ ,75 state surcharge + $.45 Administrative Fee + $10.00 Issuance. Type ofInspection Requested: 10-01) tLs-hn J./ Contractor: Y'v\..AJ to \ (L-- Address: (~ 1 ~ k). l~ A-v--- City: '7 AA-~ Phone#: 3 4 '3 - \ \ "3 State: OtL- Zip: q 7 \f-D ).- Construction Contractors Registration#: () I q fo 34 Expires: I 0 - d.. 0 - 0 :3> , 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 the testing approval n,umber to the inspector at the time of inspection. I also Understand that if I am requesting a preliminary ~pectio't the wall covering may be required to be Foved VV/J#A# ~ '\ 12-'Jo/t?t\ Signature , Date" l FOR OFFICE USE , REQUIRED INSPECTION(S):~ODSTOVEFELLET/INSERT PRELIMINARY Date of Application: I~-I 0- C; c:; Total Amount Collected: ~~fn.s-'q/ Checked for Delinquencies: / Job #: g q {0 [04- Issued By: q<' ~ ~ Receipt #: b '1(0 ~() I~ Checked for Historical Status: