HomeMy WebLinkAboutPermit Mechanical 1995-1-18
SPRINGFIELD
~
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Tax Lot #: D &'100
Job Location: 14~5 ('Ell" fl>lvd
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Assessors Map #: I 7-0?" - 2. 7 -44.-
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Address: 14~) ~dJ" fJl"J
City: S'IJFll
SDF'M O~.971?7
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Owner:
Phone.
#: 50..3- 716-2337
Zip: CI7477-2.11O
State: ni!_
Value of Yood Stove@let S~/Insert: ::2~.::22. Sb
(please circle appropriate appliance) -
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: P~L e;r ~.r-~'V~
Contractor:
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(1 J5/~/VJ L.I J
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Address:
Po. f)o-I'I"> X
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State: (!) J?
Phone #: 937-393.5'
Zip: 9'113/
City:
Construction Contractors Registration #: 'i~ }(/J(..
Expires: 5/9S-
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 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,
Signatur! ~f~
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(~
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FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOV~INSERT
~PRELIMINARY
Date of Application:
/ -/g~_ S-
Job #:
95"~~3
Total Amount. Collected: -::;:::"'6. "<eo
Receipt #: /bo:2'"7
Issued By:
~~.,...- '
~h~f~r~~istorical
Status:
Checked for Delinquencies: