HomeMy WebLinkAboutPermit Mechanical 1995-10-13
WOOD 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: 5D~ c.aSc.9<1~ ~t, o-lX o~
Assessors Map #: \9,o'lDt12-
Owner: ~\)~ ~ Ma(~ fIaVV\M\L
Add res s : f:J:fl C:a '2:.C.<tle.. \)"{ \ \! e....
Ci ty: S~{\v\o..Q\Q\~
{g~tb t\'(ke.. \V" ""-\J{'SttcJ\!\
Tax Lot #: rn?{X)
State:
(!)R
L\38:.t~
Zip ,Code:
qt.! \- q lZS-
1141<&
Pho~e: #:
Value of Wood Stove/Pellet Stove/Insert:
Preliminary Tn~oection ~$15.00 (prior to installation of insert)
Wood Stove(pellet/Insert)Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: 7'fe.. ~ 9~,^a\ rV\~~t\\01l\
Contractor: TZ A ,--0 \.I.. LtJ~eJ)Itcs.rt::='rt CON~'N2,..0c.. "t-, 0\ ')
Address: 5=15 W\\50V\ S~ Phone #:
Ci ty: F0fj~V\~ State: afZ
$.45 administrative
Zip Code:
(o~&-oqto~
Cr+ 4D 'Z...
l2.f't\
,
Construction Contractors Registration #:
q~~~
Expires:
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 was provided wi th the Wood Stove ~afety information for wood burning
appliantes 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 number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
may be required to be removed.
~ ..'
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nC"r' (~
Date
i '\ q~
, EOR~SE, ~
REQUIRED INSPECTION(S)' YOODSTOVEb,ELL]ETI~NSE~' ::)--// PRELIMINARY. .
Date of Application: \ () . \ ~ ct3 --- Job #: C\~ \ lo (~
Total Amount Co11ect(y . 4;\ 1D .\ t . :. ~ '.j
Receipt #, \~1Ao Issued By' ~'QO'J
Checked for Deliquencies:
Checked for Historical Status: