HomeMy WebLinkAboutPermit Mechanical 1995-10-9
WOOD STOVE/INSERT INSPECTION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: #." 'I1'3f ~~~ur,
Assessors Map . I(j:j3S~
-:..l(l/' k V".iS6n
Address: ~d3 (!lJ D{!O-flP. Dr,. Phone: #:
City' _~/~~J State' tJ,-- Zip Code'
Value of Yood S tov& S tovellnsert' t/ hOD. (/Q
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 stjte surcharge + $.45 admi
fee + $10.00 issuance = $26.20 total ~'
..:- ~ . // \...., d II 1\ ~ - -.\ ?"rl
Type of InspectioTl Requested: '. h nuJ -' -r~ ~\.U \.
contractor:3!ejtJ- skl!e S/JMtifk'f . ~.
AddresS' ~Y>:& ;5/'1'/ ('<,+ Phone *, R96~6.505
City' /..lJ State' f;j- Zip Cpde, 9-JvJlr
~ -
/~ 1~
-~:ON';flJe!cI (jr 77cJ7r:
Tax Lot #: ;r=t~
01,/ner:
7(/"7-,-3o<.Lf)3
97~7Y
I
Construction Contractors Registration #:~~~~~
Expires:
By signing this permit/application, I agree to call for irispectioI1(S) 'as required
(726-3769). I state xhat all the information on this permit/ap~lication is correct
and that I 1,/as provided 1,/i th the Yood Stove Safety information for 1,/ood 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 01
Environmental Quali ty or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
alSa.. un e,rs.tand t,hat. if I am requesting a preliminary inspection, the wall covering
may be 'equired to be removed.
tA~~lf~~ /t!J- q~ 95
Signatu~ \j , Date
=======================================================================================
Date of Application:
Totai Amount 'Collected:
Receipt #: \~~L\~
/'
Checked for Deliquencies:
"i ' ~ OFFICE USE'
YOODSTOVE4i~LE'0rNSERT ,V
D .I().q~
,C-!J t() . !lrj
PRELIMINARY
q~lLo31
b. '\
Issued BX: )
~
Checked for Historical
,Job #:
REQUIREb'INSPECTION(S):