HomeMy WebLinkAboutPermit Mechanical 1992-11-5
SPRINGFIELD
WOOD STOVE/INSERT I~~ECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
v.. 8~
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 13QO rkJil.ovtu..)r'J(~dL
Assessors Map #: 'I, O~:l J ~~
Owner: Y.Al~pL ~ 0,
Address: } 3,4-f) CoL.(j)y) I ~lr)od2
City: 4;\V\0~ l-P~ State: oR'
Value of \lood Stove/Pellet Stove/~ $, ~()
(please circle appropriate appliance)
Tax Lot #:
(') J 0QL)
Phone #:
/4/ - 1t:;,4S
qj Lf I )
Zip:
/ ~ ~;vY")
,
Type of Inspection Requested:
Preliminary.Inspection is $15.00 (prior to installation. of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + ~ state surcharge.
(.) LP J1Cj
, Y r\JL - ['1'\ : W'\
r~t I (JA{)a IA')ordR-t~~
l1S~Ll
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 number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
m be required to be removed.
^ ;;. !C:,vJ
. i~a ture {
J1~J.. (J
I -
Ills 1t1~
Date
FOR OFFICE USE
REQUIRED INSPECTION(S):
Date of Application:
WOODSTOVE/PELLET/INSERT
\\-~~-q2-
Jp \ S 00
PRELIMINARY
-\'
Job #:
Of'd. ISL/O
Total Amount Collected:
Receipt #:
~(~9.f
Issued By:
08
Checked for Delinquencies:
x
Checked for Historical Status: ~