HomeMy WebLinkAboutPermit Mechanical 1994-10-21
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield,. Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 'i '? ~ j F~ $;:r
Assessors Map #:. \~[)lt~,)~ 3:1-
Owner: I~({ .~~..JlJ -.
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Tax Lot #:
(1o\N)
Address: 4 J. C{ 3 p~
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City: ~tJ.I ---
f1 (/'f-
Value of ~ood Sto e/Pellet
Phone: #:
7 '16 t:;; fr
,
9 7 r ?g/
Preliminary Inspectl 11 ~~ 5.00 (prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total '
Type of Inspection Requested: \1'\QJ) S~~ (\
Contractor: ~_\~ U - . \
tate: (]J((
nsert: ~ \ SlOe)
, Zip Code:
ro
$.45 administrative
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Address:
Phone #:
City:
State:
Zip Code:
Construction 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 was provided with the ~ood 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.
"
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Date
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EQR OFFICE USE
REQUIRED INSPECTION(S): VDDDSTOVE^PE~L~NSERT ~
Date of Application: \t1. ~ \ . , Job #:
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Issued
PRELIMINARY
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By: C,\[\(\-)
Total Amount Collected:
Receipt #: \~\ ~ lQ.
Checked for Deliquencies:
Checked for Historical Status: