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: