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HomeMy WebLinkAboutPermit Mechanical 1996-10-18 ,. . SPRINGFIELD. . . YOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Stl:eet Springfield, Oregon 97477 Office:. INSPECTION LINE: 726-3759 726-3769 .... 5dq~ f1/n-fh/'a Assessol-s Map ~:' l-702~-33L/. O\lner: · ~Ja~Vlii abc{C~ .f2Ijj] Address:31QS eVJtl~{C< t:+ City: 59'(\' ~)rJ Job Location: Cf, Tax Lot #: ()(')/(J7 I -- State: Or( Phone: #: 7J.{o --)030 Zip Code: Q7'-17 9(" Value of Yood St /Pellet Stove/Insert: ~iminal-Y I:pectionis $15.00 (prior' 'to installation Yood STov. sen Permi t is $15.00 +, $.75 state fee + $10.00 issuance =$26:20 total of insert) surcharge, + $.45 administrative Contractor: . P'" -1iV1A1'~)/ Type of Inspection Requested: , Address: , Phone It: Ci ty: State: Zip C;ode: , - Construc~ion Contractors Registration #: , Expires: By signing this permi t/application, I agree to call for inspection(s) as required (726-3769). I state that all the information on. this permit/application is correct, and ,that I \laS provided vi th the Yood Stove Safety information for vood burning appliances an~ preliminari inspection standards. I furth~r 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 piovide the testing approval number to the inspector at the time of inspection. ~ also understand that if I am requesting a prcJ.iminaryinspection, the \lall covering may be required to be removed. Signa tUl-e Date '. --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- 1 FOR OFFICE USE REQUIRED INSPEC~ION(S): YOODSTOVE/PELLET/INSERT Date of Appncation: IO/lrg,.q ~ Total Amoun t Collec ted: 4.J C; f r.J7J Receipt #: 2352 q Job, #: PRELIMINARY L . q(~142_L( Issued By: !j;p '~hecked for Deliquencies: ~ .... Checked for Historical Status: