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:
, . '