HomeMy WebLinkAboutPermit Mechanical 1991-12-12
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
. Office: 726~3759
INSPECTION LINE: 726-3769
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Assessors Map #: 1 7 () Z--- ""3244
Owner: uP I/\. V\~ VVVU\ ~k:..e-
Address: t.-\ 't 60/ Do. ~"5 J '&r
Ci ty: ~ Id State: l)f2-
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Value of Yood ~tove/pellet Stove/~~" $/(7) . OD
(please circle appropriate appriance) .
Job Location:
Tax Lo t #: Ot:; q I)?J
Phone #:
'7 t{ { -'t5ZO
Zip: q 747?
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection Requested:
Contractor: G t>?J~ ]:)p cA...-()
Address: I=) ~?_7'-
City:~AJ'
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Phone #:
Construction Contractors
State: (")-e--.
Registration #: 2b 74 :::,
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Expires: 'Xl z.../rJ / CY "7
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 Vood 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 re uired Ii b.e removed.
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Signatu ~" ,() . , Date
FOR' OFFICE USE
REQUIRED INSPECTION(S): VOObSTOVE/PELLET~NSE~.~
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17./1 f Z-) q I
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Total Amount. Collected: 2h < 76
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PRELIMINARY
Date of Application:
Job #:
-q(l46?<
Receipt #:
Issued By: ro ~{A~
Checked for Delinquencies:
V'
Checked for Historical Status:
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