HomeMy WebLinkAboutPermit Mechanical 1995-5-26
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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.
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Signature-.
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...5 /2& I q.5
ba te /
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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: ~
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Checked for Historical Status:
Totai Ambun t ',Collec ted: