HomeMy WebLinkAboutPermit Mechanical 1992-8-28
;:a,..HIN....r-IR:.L.U
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S,treet
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
Job Location: \ \C\~ ~,\(\J\H [\ 1
Assessors Map 11: \1 f)'?J'2A a I
Owner,: '\(~ r\ (, f'()L,
Address: \\C\~ '-- 'C\r\U,l)) . '.(\\ Phone 11:
Ci tY0D~,JL State: l \LA Q fltJY\,
Value of V~Od S ove/Pellet Stove/Insert: f\ () }J
(please c rcle appropriate appliance)
Tax Lot
11: ()()?[)q
~o-u~'L~
Zip: C{ltll
Preliminary Inspection is $15.00 (prior to installation
Vood Stove/Pellet/Insert Per~it.~ $1\.00'+ $ .75 state
Type of Inspec t ion Reques ted:4 ^ Q 1 ( rY\ )
of insert)
surcharge + $10,00 Issuance.
Contra~or:
Address: '"
'--- .--' -
City: ~ State:
Construction contractor~gistration 11:
------
~ _ Phone-1l~
/'
Zip:
Expires:
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 required to be removed,
~S/~ Q I'~ '
~nature ~
S/ZB/9c
(
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/~~/INSERT
Date of Application: ;:s '~'L1~ Job 11:
\~~
PRELIMINARY ~
l1 ~\~n3
Total Amount co~~e~
Receipt 11: l Ol..Jc}:)
Issued
/),
BY~~' f'V'A
~.
Chec d for Historical
~
Checked for Delinquencies:
Status: