HomeMy WebLinkAboutPermit Mechanical 1999-3-22
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WOOD STOVE/INSERT INSPECTION APPLICATION
_ CITY OF SPRINGFIELD
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12 .~ '5 CSQJ1MUNITY SERVICES DIVISION - BUILDING SAFETY
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Office: 726-3759
INSPECTION LINE: 726-3769
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Tax Lot#: ()'1l.{ 00
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Phone#: ?'1/-Lj?8'y
Zip: ?'7ti -/'7
State: Gr,
. ellet s~ert: POW de>
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPellet/Insert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance. \\ \ '\ i SJ2\
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Type ofInspection Requeste~l~j-:!CW .... .~ ',,"III,", ''''''oa.u:r. SHALL E
- - - '1IIiU I i.:n:VII I ., XPIRE IFTHE WORK
Contractor: tJ hi )./ L Jt,.. A' ,.,~ Jf)RIZf::D UNDEiiTH'~ PI=RMIT If:: NOr
Address: '1'5 CAlC cf./ltNlt/l'.~NU;~o~~ !C'7~Qotti:" ~rr
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City: <3 /J~ !'t4 State: OIL Zip: f 7 '(7 7
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Construction Contractors Registration#: Expires:
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 ifI am requesting a
p'elimin::~n, the waU covering may be reqnired to be removed, .
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SignatmJ-'~ Date
"z;e:.'i FOR OFFICE USE,
Date of Application:
Total Amount Collected::~2naJ
REQUIRED INSPECTION(S): WOODSTOVEIPELLET/INSERT
3/;.i-1'1'7 Job #: 1f~ '] 71 /7
Receipt#:p~ 3~2..~suedBY: 'p 4JJ
PRELIMINARY
Checked for Delinquencies:
Checked for Historical Status: