HomeMy WebLinkAboutPermit Mechanical 1992-10-6
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 7~'3 r- F~~//.A//~ ,,?CYL::>
Assessors Map #: /7"'i1t''3-2~-6/? Tax Lot #:
Owner: 7:?/r.#--/::?z r-L #~L
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Address: ~6/~..
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Value of lJood Stov~U:t Stove/Inse~ /~ ~ .,,-e>
(please circle appropriate appliance)
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Phone 4*: ?Y7"'Ji?(!!!S ~
City:
State:
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Zip:
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Preliminary Inspection is $15.00 (prior to installation of insert)
lJood Stov~llet/In~~r1>Permit is $15.00 + $10.00 Issuance + .~ state surcharge.
Type of Inspection Requested:
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4.e;~ __ State: r'?~ r
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Construction Contractors Registration #:
Contractor:
5;",.,.: LC-~~.-7~/Y"$"
#: '7~6~7
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Zip:
Address:
City:
'7~~ Expires:
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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 ~orrect and
that I was provided with the lJood 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 rem e
p~
FOR 'OFFICE USE
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Date
Signature,
REQUIRED INSPECTION(S): VbODSTOVE~LLET/INSERt)
4-
PRELIMINARY
Date of Application:'/~.J77-
Total :Amount Collected: '2'5"',7S-
Job#:
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Receipt #:~i.f~'-I
Issued By: .. ~ ..
Checked for Historical Status:
Checked for Delinquencies: