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HomeMy WebLinkAboutPermit Mechanical 1999-12-29 . . SPRINGFIELD WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD COMMUNITY SERVICES DIVISION - BUILDING SAFETY 4 "9 AMT RECD:! $ 26.50 CHANGE: CASHIER:QOl 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: <:2-~ S -- (,)" ttl.....h J d.. Assessors Map #: /?~"'Z...;? '.:3 ~ q Owner:~ ~ ~ A Q..O{ f' t.~ vV Address:c-t2.. 9 ~ (', Y b r-.A /' f1.. r , __ Tax Lot#:~/o~ City: C' IP Y"{) _ 0 , Value of Wood Stove4[ellet St~;nnsert: / 'A 5'P ~ State: fZ)/((C Phone#: ?~b - Y5~' Zip: 5! 9417 ~ (please circle appropriate appliance) Preliminary Inspection is $15.00 (prior to installation of insert) Wood StovelPellet/Insert Permit is $15.00 + l.OS state surcharge + $.45 Administrative Fee + $10.00 Issuance. Type of Inspection Requested: ? C:C:tC;t>T ~y & Contractor: ~#~~ Address: Phone#: City: State: Zip: Construction Contractors Registration#: 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 Wood 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 n,umber 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. (/4?/~~_ (/ /' FOR OFFICE USE Signature /'2- - 2.. ?-719 bate REQUIRED INSPECTION(S): WOODSTOVE~SERT Date of Application: /::;f....:z... ~ ~ 9e:::? Job #: V PRELIMINARY ~~5? Total Amocn. Co II ,,"d::;;z.6 . "5.:> R"cip. #: U'Y I"ood BY:'l~- · Checked for Delinquencies: Checked for Historical Status: