HomeMy WebLinkAboutPermit Mechanical 1993-2-23
VOOD STOVE/INSERT INSPECT-10N ''APPLICATION,..."t,." 1.001". foilo"lng
CITY OF SPRINGFIELD ~ nJIIQ. ;;:nc.s QO("cll~,:)t rO:jUJI'3 Sp3CllC !?rl"l Ut3
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BUILDING SAFETY DIVISION
~Ol,r_~__
225 Flfth Street
Sprlngfleld, Oregon
Ot'....
97477
Autnonzad StgnatJre
Offlce
INSPECTION LINE.
726-3759
726-3769
Job Locatlon: 1t-I9 if> (11-1~k'
Assessors Map D: 1703;;l..,--\ 33
Owner' Q"fH< L.~ cI- CLA-I R...G:"
.9PK' ~G r- I (=-LD
Tax Lot #. CfDB
I-i 111
Address. J y.q G:> .c2.. i-+E:E: f, Phone #: 7'-+ iD _ '--/ 0 ~ cl,
Cl ty: 596<--1~G, F f E?-D State: OK.. Zlp: 0,; '-III
Value of(VOod Sto~6Pellet Stove/~~rtli 11'1 3 ~
(please clrcle approprlate appliance)
Prellmlnary Inspectlon lS $15.00 (prior to lnstallation of lnsert)
Vood Stove/Pellet/Insert Permit lS $15.00 + $10.00 Issuance + $~
1rJ
state surcharge.
Contractor
fEfGF=cT
,T!r?--:-/~~~ _
PA-RNJ~5
r'-..-= _
Phone D:
3Lf5- go5o
Type of Inspectlon Requested
Address: 7L? ~.r~~-
Clty ?/~ ~L}?~ State' c:::>/< _ ZlP: 9'->Vc:> ~
Constructlon Contractors Reglstration D. CL6 #7~ExPires: /~ -:::;>-9{r
~
By slgnlng th,S permlt/appllcatlon, I agree to call for an lnspectlon(s) as requlred
(726-3769) I state that all lnformatlon on th,S appllcation/permlt IS correct and
that I was provlded wlth the Vood Stove Safety lnformatlon for wood burnlng
appllances and prellmlnary lnspection standards. I further state that the appliance
I am ,nstall,ng meets smoke emlSSlon standards as set by the Oregon Department of
Envlronmental Qual,ty or the Federal Envlronmental Protectlon Agency and I agree to
provlde the testlng approval number to the lnspector at the tlme of lnspection. I
also understand that lf I am requestlng a prellmlnary lnspectlon, the wall coverlng
may ~~red;)o b~O~ /j ~
h./ft~ /J I AA2+ ~ 2-::L3-93
Slgnature Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
PRELIMINARY
x
Date of Appllcatlon
":?-2"?-"3"'='
Job #
9:S:>~.727 :;r
Total Amount Collected.
-
/~-
Recelpt D:
76/~
Issued By:
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Checked for Historlcal Status:
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Checked for Del,nquenc,es.