HomeMy WebLinkAboutPermit Mechanical 1994-9-8
. .
YOOD STOVEIINSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD 1~,~ D n
BUILDING SAFETY DIVISION l~ JU
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 50!:'1: r:<.s'1.fiu'a.. Or.
Assessors Map ~': /g-c>< -cs-r-c::>6 Tax Lot~: <=;2-:;'4>8'
Owner: /A1a..rk. ,4. ('oslc.- ~ c.Q..Jor(~"'- 15u,ya.",-,f
Address: ~D '2.<6 +:<,vsyfl....:G.. -0.... Phone:~: 7U ,- G 77..-'1
City: L...?~l&. State: ()Vq Zip Code: CJ]L(7f>
<--' $(
X Value 0000d Sto~/Pellet Stove(Insert'!) t{;-O - f) cO
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10,00 issuance = $26.20 total
Type of Inspection Requested: ~~~ -~~~
Contractor:P.~/7?4A.P-:'~~ 0A~ ~~~c!"'"7:)
Address: C/2~~ ~-~.- c:Azu~~/# Phone~: ~//'?7
Ci ty: ~ - :r .i""'~.A-.....JE:.... State: ~ - Zip Code: c::l7':'_-::;:~
Construction Contractors Registration ~:2~'2~O Expires:-/&>-'""Y-~Y
By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permitlapplication is correct
and 1:hat I was provided with the Yood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards' as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
may be required to be removed.
/"~
e-U4 J (..L
Signa ture
s~P, "'D J ft 'I
bate
=======================================================================================
FOR OFFICE USE
REQUIRED INSPECTION(S): ('WOODSTOV~PELLE~
~-$i'-9'Y
Total Amount Collected: ~~. ~
PRELIMINARY
..
Date of Application:
Job~: ~ /3'97"
Receipt ~:~~~~
Checked for Deliquencies:
~
Checked
Issued By: d~
for Histor:ca~~tus: ~