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HomeMy WebLinkAboutPermit Mechanical 1996-10-9 I STOVE/INSERT INSPECTION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fif th S t l.-ee t Springfield, Oregon 97477 Office:. 726-3759 INSPECTION LINE: 726-3769 .... Job Location: - :~3L \i:), Le"t-e()()~~ /7~ 3-:<7'7"'7' ~~ w. ' (e (\.t-..e ('\ ",..JJ ,. Assessors Hap j: O....ner : ~~\ Tax Lo t ll: c:J5'"3&:>-o Address: 3~""2- Ci t~: S~.,Qd. State: 0- Phone: ff: 74 I - eo Ie Zip Code: q,ct 1'7 .' Value of Vood Stove/Pellet Stove/Insert: 14Co~ .r Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative fee + $10.00 issuance = $26.20 total ' C'on t rac tOl-: . ~ij'86:3- Addres~: - \2..0 b~ A ~~~ ~~ \ .} '\ I Ci ty:c. 4--e~Q..j ~ /". . . ,;:-,,:::- -j/~/yz>~L::::.. ; /" " f""f"...." \ \' ed.e ~c.. ^ ?CCL.IF?- ~v&, , Type of Inspection Requested: Phone ~: "('-II-()~/'7 q7V~;;-' State: o. Zip C;ode: \. Construe tion Con trac tors Registration #: to l S'Z..c;- Expires: ;;g-g..~? By signing thispermi 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 ....as provided vi th the Vood Stove Safety information for vood 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 0{ Environmen tal Quali ty or the Federal Environmcll tal Pro tee tion Agency and I agree to pr.ovide 'the' tes'ting. app'roval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the ....all covering may be required to be removed. ~ ~!::oL Signature /tJ.r'?~ Date ======================================================================================= FOR OFFICE USE REQUIRED INSPECTION (S) : \.lOODSTOVEq'1!ELLEt'{SINSERT. Date of Application: /?'-q....~6 ~ PRELIMINARY Job 11: qG/3~2 Total Amount Collected: '2.6:~c:.:> '~hecked.for Deliquencies: j Issued By: ~~;. ~ . /pr' , Checked for Historical ~atus: ' -- , Recei p t ff:::2 ,y&?;>'