HomeMy WebLinkAboutPermit Mechanical 1992-10-7
SPRINGFIELD
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
SprIngfIeld, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Locatlon: 2872-. r iN ,vtJk--.r, K
Assessors Map It: (KvZlJIo( Z---
KcvV-e-V\ C1tvi'~~~
Address. 3t57Z-. O.-ltov}i'iLJ'>4- Pr
~HJ
Tax Lot #:
Ol7Cb
Owner
Phone It:
71./7 - 0 t;~ ()
C/7t..f7'Y
CI ty:
L' ~
Value of Vood Stove/~let Stove/Insert:'~
(please cIrcle approprIate-applIance)
State:
/V7 /, ~d3
ur ~~- -
{'c(97.C0
Zip:
PrelImInary InspectIon IS $15.00 (prIor to installatIon of Insert)
Vood Stove/Pellet/Insert PermIt IS $15 00 + $10.00 Issuance + $~
1\,\ s 1- cill~ - O-P J!J:p
I
state surcharge.
Type of InspectIon Requested.
Contractor: ya,1A '?€.-r!vtYl<:
Address ,~S~ AI 3?1/1a.
SD fJd
V
'bt
Phone It:
CIty
State:
liY2----
1 Z>Z-/2::>
ZIp:
7 ~ zL/ 1./7)
q 7419
-0- 7 -93
ConstructIon Contractors RegIstratIon It.
ExpIres:
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 Vood 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
Envlronmental 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 removed.
,
~R\lrc) CmJJd-!)Li~KQr-, Date 1('\'"1) O:::J_
S~g.};ture W
FOR OFFICE USE
REQUIRED INSPECTION(S):
VOODSTOV~
~ PRELIMINARY
Job It tf'7/{;; 71\
Total Amount
Collec ted
o L{( cr
I/)- "7 -j '2
Z--0 - 7C7
.0-
Date of ApplIcatIon.
Recelpt It
Issued By:
V/l/1^
0'
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Checked for DelInquencIes:
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Checked for HistorIcar Status:----