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HomeMy WebLinkAboutPermit Mechanical 1999-3-22 " /' WOOD STOVE/INSERT INSPECTION APPLICATION _ CITY OF SPRINGFIELD ... .~ i . 12 .~ '5 CSQJ1MUNITY SERVICES DIVISION - BUILDING SAFETY .::l~'""'o(/)"'c O.:)-'Cll"'O , ;- c ~ tffi.~ jfii Street .g g ff lrSfl)'r~~ld, Oregon 97477 ;::, ID ..., _ :;e- _ _ . -&';;(/)O""'-CllO;:::-' "'OCll ~-_.~ FD _ 0". <. "'" -Cll ~ '" ('I) !.j;. S~ 20>(/)~.oC\J ' $I ;: Cll 5 'aot):L~tltion: 'c 5 (; CJ:)&~02.:::>C") 01:),c:S0 OcC::> f? 2 ,..:.: 0 .S~6SS@S Map #: I.;;; Q. ..: .... CJ:1 ..: 0>(0 OOIDg:QCllfE I f/\ ~ ~ c,..:. 0 ~~ef;<,'/ .JOJ/l O Cll 0 ;:::., Cll Cll '-- _(/)00CJ:10~1... ~ Cll . c- <U. -.$ //')/ <: -::; 8 C\J 1;: ..c:t\Mress: 70 b iJ.J 1...._ li") ;::, .... J:r'Q) , f-:. S co 0) j? f? 1... 0 ~/J I- 0.2 CC._ ' . - <:{ =a ~ q: ci 7g ~:: G . ~ ~ 0 0 Q) 0;::, L/~ ,,- Zf;o . 0 Value 0 ood Stov Office: 726-3759 INSPECTION LINE: 726-3769 Cd /103' 7 'TV (-- ~je-rS 4./ C~%i1;'l (,~, r':t/' / ~ e-?(,I'eh 11 /""y 1.__ f]( iJ. Tax Lot#: ()'1l.{ 00 blvcfJ 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\ ~~\ €)~ \ ._ >t01Je,(OTJCE: 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 f\1'H ,~u 't;yP!1 ~~~fQb. City: <3 /J~ !'t4 State: OIL Zip: f 7 '(7 7 I 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, . .I M~ 7-2Z-P? 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: