HomeMy WebLinkAboutPermit Mechanical 1999-11-4
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICE'S DIVISldNCEm&ErNG SAFETY
THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZEDUNDERTHISPERMITI~NOT Office: 726-3759
'1NSPECTION LINE: 726-3769
COMMENCED OR IS ABANDONED FOR
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Job Location: I G\ 4 \ L.CA..r"1tr l (U(y[> J ; ~r n n ~ J. 0 R C( I Lj I (
Assessors Map #: /1 () -:5 2 5 3 :2 Tax Lot#: I~ 20 ()
Owner: R Oheft 9 5k'ohn jI) -ve FA''" I ~
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Address: lC14t fur -4> J\/" l a Jt.f--"
225 Fifth Street
Springfield, Oregon 97477
City:_ SpY-t~n3~Lc;P State: OR.
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Value o,<:!! ood ~to3JPellet Stove/Insert: ..t, OX) , 06 (please circle appropriate appliance)
~i!ninat:y Inspectioq}s $ I 5.00 (prior to installation of insert) ,
(Wood Stov~e1iet/lnsert Permit is $15.00 + LOS state surcharge + $.45 Administrative Fee + $10.00
ISSUance.
Type ofInspection Reqnestoo-jl1-DL~ I v1tJ2"rnls ~
Contractor: ~ B G s-tove_~ I..:.-:\~fj,..rbhj.--hf..~j;~..c"'+'
, 'f~t~;~'I~~'~d;~t~d'b;th~~o;~;~~-~~~t'
Address:::P() &JX.. \ O~ I ,'" __~'u "'__,_ _ ......'u_.._ .., I?hgnet~': ~~,~,~- 2S ~ \ P->
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City: nekJr X'- i~<?tsl1yt~op~re~,:?_t~~<:~?~ ~~~?~~:~O~,~
-- vv~u. U ..Iay VIii..II,UII t VVt-'I\JV ",-n U gM . -.-- - J
. . " l<Ori:iiNl! ~;:(; ('ent0~, (Nots: tile telephone
ConstructlOn Contractors Reg1stratlOn#: -:.....r 0' . _ - _ _ '"'.. _Exp,lTes:,,,,.., "!^.:.l':~....+;....",
II Illut:111VI '1IIJV,vgUIIUl"",. ..v,......~.......
B . 'th. 't/ I' 'I llCent6ris l-ROO(-3)32-2~j4M"d ( 263 69) I th
y slgnmg 1S penm app 1catiOn, agree to ca rot an mspection s as requITe 7 - 7 , state at
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
,/P'Z::J;-::; b6;~~~aY be required to be removed / / /'11'19
~ A-Y~ ' ,Date"
FOR OFFICE USE
Phone#: 14Lt~~i3~
zip:C7tl4'1/
REQUIRED INSPECTION(S): WOODSTOVE/PELLET/INSERT
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Total Amount Collected: 4/, ~7J Receipt #: 03 b oq 7-
PRELIMINARY
Date of Application:
Job #:
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Issued By: 4/ w,J
Checked for Delinquencies:
Checked for Historical Status: