HomeMy WebLinkAboutPermit Mechanical 1998-4-1
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SPRINCFIELD I
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\lOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth SUeet ~~~ Office:,' 726'-3759
Springfield, Oregon 974 77 Tl\t.~etTJ:ON LINE;-- 726-3769
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Job Location: S-2 y~ i)A)~~~~~~~~~~~~~~;~~O~
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Assesso r s Ma p :' /~ ::> j.~ \";;~~\) \)~",~ ~1!>1'l Tax Lo t ,. 'f III '-f .
O,vner:_~:: 'A~CL . 'rv'ell ~\)~~, ,~~c,~\) #\(.~O\)., '
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Address: ,S 24~ '_ AlsY ~J ,~\~ Phone:' ~';-7t.i(;,~'?~(~..
City: 'S,ptlJtJr.I=-/8-I{) .. . State: .~ ()~ZiP Code:. q74/1
Value ~f \lood Stove/Peliet. $tovelInsert: L~ Of ') . .
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Const,ruction ContI;actors 'Regi'stI:'ation ft: Oc, 77'L..}I
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Preliniinat.y ~tion is 515.00 (pJ:i9f to installation of. insert) ,
\lood Stove~elletjI~sert Per~it is 515.00 +' $.75 state surcharge + $.'5 adminiitrative
fee + $10.00 lssuance = $26.20 total '
Type of InsPri tion ,ReQues ten -r::l' AL- (, ,I (' , . -
Contt-;actor: l~t.~DJ f/Il..dEs:3SI 0 AJA-<. ~, ~)({.{-. ,
Addr~ss: 2-1-''' C J ~ 'r\, 4 v'c p'h'ne #:: If(l/- 9tr:n '
City: (~LX~ t=10E-, 'Sta~e:_a ", ZipC;ode:Q74-0J'
C(j9Y,
Expires:
,By signing ,this 'pet-mi tlapplication, I agree to call for inspect'ion(s) as required
, (726-3769). I s ta te tha t all the information c/O this permi t/applica tion is correc't
and ,tha t I vas provided vi th the \lood Stove Safety' informa tion for vood burning
appliances and prel~minary inspection standards. I turtherstateH' that-the appli?nce
I Cim installing' meets smoke ,emission standaJ~ds 'as set by the Oregon Department '. of,
, Environmental Quap ty 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 pt-climinary inspection, the vall covering
maybe required td, be I:'emoved.
J;:~~ u4S..f ~/) Ec. . L c..
SIgnature 'i~ ~r.. .
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FOR OFFICE
USE
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PRELIMINARY -,
REQUIRED INSPECTION(S): UO?DST9VE/PELLET/INSERT
Date of Application:, 4/ IS/crt " ,
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Total Amount Collected::D11.1. /100
Re~'eipt II: OI1tf3S
Job II:
9 ~o.L/(j c; ,
Issued l3y:
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'~Checked for Deliquencies:-1l~
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Checked for' HistoLi,cal S,tatu~:lJ fJh!._..-,