HomeMy WebLinkAboutPermit Mechanical 1994-9-16
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YOOD .STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: ~~:;C)
Assessors Map #: /7 t9 3 24-
Owner: k )rl/uv'IA....l tLO'i (;)
Address: 72 3R'I (: L - b~, 1 TA
City:<;:pn.'l\Je, 1:1 E-~ State: <<W
Value of Yood Stove(Pellet Sto';'~Insert: ~/~O QQ
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Tax Lot #: (::)'27.0'/
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Phone: # : 7 z..Co - 0 L ") l
Zip Code: ql L/il
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Preliminary Inspection is 515.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is S15.00 + S.75 state surcharge + S.45 administrative
fee + S10.00 issuance = S26.20 total
Type of Inspection Requested: r;1JAL AF715tL ht..a:::"".,utllll}(,
Contractor: i? A\.D H LL'\"',.:( (lJ'A.lt:1? r ~~neLlcTIW
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Phone #: Cc,){< - 09,,,
Zip Code: Q7t/OL.
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By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided wi th the Yood 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
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SIgna ture I Da te f
Address: 57 S- w,LW()
Ci ty: E lIC.t-=-^ 'IC:::'
State:
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Construction Contractors Registration #: q-S;'5;S-1
Expires:
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Date of Application:
Total Amount Collected:
YOODSTOVE~INSERT
0//4;15' 9t
-----?/ 2.0
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FOR OFFICE USE
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PRELIMINARY
REQUIRED INSPECTION(S):
Receipt #: jf74D
Checked for Deliquencies:
Issued By:
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Job #:
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Checked for Historical Status: