HomeMy WebLinkAboutPermit Mechanical 1992-5-11
225 Fifth ~treet
Springfield, Oregon 97477
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Office: 726~3759
INSPECTION LINE: 726-3769
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Job Location: 3/f 7~
Assessors Map 1I: )002 n(~
Owner: I/oI/J O'~til k)Ae/Sh'A1r~
Address: 38 7~ :r~s..c.?el- k'c1",
,~-<J r,'NCj !ZPlc;; State: tJlZ
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Value o(Vood Sto~Pellet Stove/Insert: Icr7"'fJ
(please circle appropriate appliance)
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Tax Lot 1I: ;)/30/
Phone 1I: 7'1;/- gPI P
City:
Zip:
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Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection Requested: 7Pee<:;7/11JlJJAJ.::. IA/L),Dt?<;2(J:ns
Contractor: -// ~_. :--I/-'!- /~_ 'rr n /k5C!..- 0'7f,,?,1.<JCf S~, (T!?j 1'&17 ok)
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Address:_ )//7,4 ,~.s~~,~ Cor G?bi-~.
City: f:'U9 ~A/e State:
Phone
1I: '/fJ.)'-5'"' 3 7f/
Zip: 97Yo.2
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Expires:
Construction Contractors Registration 1I:
By signing this permit/application, I agree to call f~r an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was provided with the Yood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a prelIminary inspection, the wall covering
may be required to be removed.
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Signature
g//J/92
Dat'e
FOR OFFICE USE
REQUIRED INSPECTION(S): ~uuu~ro~/PELLET/INSERT ~ PRELIMINARY
---
Date of Application: <;;:S///Z92- Job 1I: ~./ rJ CY '3
Total Amount Collected: 2$;75:"
Receipt 1I:
5$5'5'
Issued By:
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Checked for Historical Status:
Checked for Delinquencies: ~