HomeMy WebLinkAboutPermit Mechanical 1992-9-29
~OOD STOVE/INSERT INSPECTI
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 FIfth Street
SprIngfIeld, Oregon 97477
OffIce'
INSPECTION LINE.
726-3759
726-3769
Job Locatlon: ~~n'l~ ~XtQX()tQJL l\J\~UD
Assessors Map #: \ so~a 0 \ ~ Tax Lot #: () 117 Q()
owner:~)\ 0 f\ ~l\ .1S,\-~~QX~~ ..
Address. :?JnlJ ~ Q1\Q \(ntlQ,gJ. Phone #: '14\ ~w'CftC)
CIty. l-'{JJ\. i 1\ iLQ Of{) State: (Uln.J)M ~ Zip: 4'l4'l Y
Value of ~oo\ Stove/peil t \ tove/Insert: n lQJ6-
(please circle appro ate applIance) I
PrelImInary InspectIon IS $15.00 (prIor to InstallatIon of Insert)
~ood Stove/Pellet/Insert PermIt IS $15.00 + $10.0Q Issuance + $1.25 state surcharge.
Type of InspectIon Requeste&) ,LY\o ~ I f'(u./lfl.!li {/
Contractor ~, (\
. ----- - ~
Address _..- -~ -Phone #:
CIty. ~ State: .------Zl-P:-
ConstructIon Contractors RegIstratIon #:
ExpIres:
By sIgnIng this permIt/applIcatIon, I agree to call for an inspectlon(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
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 removed.
~(u~r:'
Chi J--D---r 1:)'-.-QA,'Y>O
, . . .) FOR OFFICE USE
q :JCj q~
Date -
REQUIRED INSPECTION(S)' VOODSTOVE/PELLET/INSERT
q ~C\q2-
\~CO
Date of Appllcatlon
Job #:
~
PRELIMINARY ~
qA \~\fY)
Total Amount Collected
Recelpt #. lo~
Issued
II ~
( J) AP\.
By--: --;:-7). d... :LA...
'- 'che~ked -;or H:storlcal Status:
Checked for DelInquencIes: