HomeMy WebLinkAboutPermit Mechanical 1993-1-20
(
VOOD STOVE/INSERT INSPECIION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 7 39 ~, 70 ~
Assessors Map #: /802- 02- '2.,.. 2-
Owner: :y ~i I~ A e.1-E~
c:' -u\ k_
Address: 7~q. ~ /u
Ci ty: S'D.eJ/t1C')'= JEu) Sta te: f5"}
Value of ~oOd s~ove~et S~Insert: ~/~~
(please circle appropriate appliance)
Tax Lot #:
/?/6ez>
Phone #: 741- 4-1/0
--.Zip: c:j';(t?y
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $~ state surcharge.
,11?
Type of Inspection Requested:
Contractor: lEe I~Lll1 CoAJS'7"l2.tJc..TJO~,-J
I
Address: S-7\ LU It-Sou
Ci ty: GU(~f="AJG
State: ~
Phone #: ror~ -Oq ~~
Zip: C17t.(O 2__
lIJfq3
Expires:
Construction Contractors Registration #: -;;'72CoO
" I
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 Yood 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 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~ed. .
r;~()U:SS~f>€LJt4aH=~ ,~.&lY o..roJ/\ (1_1,,~ .h_1/ P. ) /2LJ Ie;,
. SIgnature, I .\-,~ ... Datk (
FOR OFFICE USE
REQUIRED iNSPECTION(S) ': YOODSTOV~ELLET'2}NSERT. ~
Date of Application:. 1-2.0-5'? Job #:
Total Amount Collected: 2- 5. 7S-
PRELIMINARY
'73cm 7 CJ
Receipt #:
72.17
Issued By:
#~
~ - ,
Checked for Delinquencies:
-L/-/
Checked for Historical Status:
~