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HomeMy WebLinkAboutPermit Mechanical 1993-4-15 ~OOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Assessors Map Owner: 'j) A( ) ( Job Location: q'l~C-.. bA'<:;.M S:T. t #: /?~-:;:z-~i {R)FAlt=, ,A Address: <..{~~~ i\~ ,Sl../ c:;" I. City:Sf/G/U~F/r::U\ ( State: Of( Value of \lood Stove~'llet Stove/Inseq,;t1Zc(,...q ~ (please circle appropriate appliance) Tax Lot #: c:::? ~~ Phone #: 7l{)-"5 <.I, ( Zip: Q7tf7'it Preliminary,Insoection is $15.00 {prior to installation of insert) ~ood Stove(PelletlIns:9JPermi t is $15.00 + $10.00 Issuance +, $.75 Type of Inspection Requested:ff(~,~"~r ht2e:-::bLt4CF. / F'IIJA,L Contractor:Cc-c-:- IJOLC_L1 ~ONS'fftU~T/(J0' t - I. ') I Address:-.l7, 0IL~JLJ state surcharge. - Ci ty: _t- ~u~ co;: I... )(C State: ~ Phone #:~r~ -oqCo~ Zip: q)t/{)"( Expires: tt \ q'~ Construction Contractors Registration #: 5'"7l.CoO 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 \lood 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 beeq i:i'~~ k- IS- \ ,::,,,~_ Signature - - Date , FOR OFFICE USE REQUIRED INSPECTION(S): ~OODSTOV~~T/INSE~ ~ PRELIMINARY x Date of Application: l/7h-'7? f'p. 7::;- Job #: ~~5~~ Total Amount Collected: Receipt #: &'~ Issued By: /:?~' //r ' Checked for Historical Status: Checked for Delinquencies: , . '