HomeMy WebLinkAboutPermit Mechanical 1999-3-29
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SPRINGFIELD
te hI> egon Utility
WOOD STOVE/INSERT INSPECTION APPLICATION Notifioation enter. Those rules are set forth
CITY OF SPRINGFIELD in OAR 952-001.001 0 through OAR 952-001-
COMMUNITY SERVICES DIVISION. BUILDING SAFET'()090, You may obtain copies of the rules by
calling the center, (Note: the telephone
number for the Oreg<lJJflilll!jtm6l1jq,)9tion
CINlWOOlTI6l>lJh~:2~~769
225 Fifth Street
Springfield, Oregon 97477
Job Location:
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Assessors Map #: /, II 1, ""\ r. "
J}6/1/A lei 7 A-c..k~<> ~
Address: 2(, F ( CA-K~
~ 6 City: 5/J(U-y,/A Ire/d State:
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W f- N.alue of Wood Stov let Stov sert: / ,j u v
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!!:: ffi 4!l"eliminary Inspection is $15.00 (prior to installation of insert)
~ ~ ~ood Stove/Pellet/Insert Permit is $15,00 + $ ,75 state surcharge + $.45 AdministrativeGFee 1-$-10:00
ii: X ::tSsuance.
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::l W TvnA ofInspectlOn Requested: ;;"V/bN ~i _ J .~: :.? ' " . ":7 ~ ,_ '--:-
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~ =:' eo'Kiractor: rlJ.i.:!~b"),-,~' ll/jA
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ffi f: ,A~ess: ,n' .._>1 ~ ~'\-tf):1"""
C ' Cii: ')f~JV7r;EI/ State:
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Construction Contractors Registration#:
Tax Lot#:
10 /0 l/
Owner:
Phone#:
7'fLf- <:Flc;' /,
Zip: 17 tf7 7
OIL
(please circle appropriate appliance)
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Phone#:
7LfY, 'tIC) C-
<i'1'f77
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Zip:
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
approvall\umber to the inspector at the time of inspection. I also understand that, if I am requesting a
PrL~2ec;'Ci1Je~;;r~K~/~_ 2 q _ 9q
Signature G/' , Date
FOR OFFICE USE
REQUIRED INSPECTlON(S): WOODSTOVElPELLETIINSERT
1/2-1/17
Total Amount Collected: J-/, 2.-<1
Date of Application:
.3-31-'ii
Job #:
PRELIMINARY
!/Y()'Iv8 Cfl61o~
Issued By: d ~
Receipt #: () =3 ." "3 2..6
Checked for Delinquencies:
Checked for Historical Status: