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HomeMy WebLinkAboutPermit Mechanical 1995-5-26 -~ ~ WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fit th Street Springtield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 ~IO Assessors Map #: /703- 2 (,,' Owner: 5V\CAvCY\ G\e~s'h5 Address: ,& 10 Ce(\r\\(\G\\ \ ~ IV D I Ci ty: SD'(\\\C\ -0 elA ., U Value of Vood Stove/Pellet ~-tt~~\ 13 I \J~.-r f3 Tax Lot #: II ~..o Job Location: Phone: #: 11../7- ~/47 <:1'411 VJ) 55 -.:zr -IN+C1 ~f+05 .....L..__ S'1>~' OK. Zip Code: A~cgt: L I I Stove/Insert: . u JNS-p;l/(eCJ... State: Preliminary Inspectiori is $15.00 (prior to installation of insert) Yood Stove/Pellet/lnse~~~t--is_$15.00 + $.75 state surcharge + $.45 administrative fee + $10.00 issuanc~/$26.2~~:::> Type of Inspection Requested: vY'C\. \ II Contractor: Ye ' o\d Town 54" Cny\ ") \N~'^~\~ Phone #: ~ 12Co-' 5 82_ Address: City: C-t<-5t.Ve\\ State: 6(< Zip Cpde: ,Construction Contractors Registration #:62'3 [3 , ,Expires: '1 (4 ~l.o . II IcIer\,;, , ,t C!f. , s:-i:-~g thiS, permit/application, I agree to calliO, iinspection(s) as required 7726-3769~ I state that all the information on this permit/application is correct and t~I "'as provided ",i th the Wood Stove Safety information for "'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 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 lam requesting a preliminary inspection, the ",all covering may be required to be removed. ,. ~~.7 Signature-. --'=> ...5 /2& I q.5 ba te / --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- , ' FOR OFFICE USE REQUIRED INSPECTION(S)~DST~ELLET/INSERT Date of Application: b/~~C-" I ;?i ?-o PRELIMINARY No, q c; r:l '7 ~ c.,-- , ., 0.-, ,.. - Job#: Receipt #: 17:;:2?- C~ecked for Deliquencies: ~ Issued By: ~ -~ ' Checked for Historical Status: Totai Ambun t ',Collec ted: