HomeMy WebLinkAboutPermit Mechanical 1999-1-25
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SPRINOFIELD
WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
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Office: 726-3759
ATTENTlON:Oregon law 1N$P~;I~~I!tINE: 726-3769
i . fo!~?w rules adopted by the Orennn I It WI I'
Ix j 'UU"~allUfI venTer. Those rules are set forth
I' \ J ~J~tR 952-001-0010 throU,ah OAR ~C;~_nnL
. .' uu may OOtain Copies of the rulMi P
17 h S '{ lj L. '\ calhng the center. (Note: !fax <<&6t1tJhJkill Y2- 2.
L L + "UII/UtI' 'orm~ Uregon Utility Notification .
Owner: Ar.. _ L~ e....r Center IS 1-800-332-23441
Address: ( \...~ q 1 (i\:.., .J Phone#:
'City: < f ~ ~ ) State: (l {( Zip: ~ ~ '-\. ~ 'I
Value of~ellet Stov~ .I (j()(') . ~ (please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation ofinsert~OTlCE:
Wood StovelPelletlInsert Penn it is $15.00 + $ .75 state surchlfrge&-I$:~5r1'dministrative Fee + $10.00
Issuance. " ..." V J J "MALL ti:XPIRE IF THE WORK
. r. \ AUTHO~'ZED UNDER THIS PERMIT IS NOT
Type oflnspectlOn Requested: ~,' '-"-1 COMMFNr;:=n OR IS ABANDONED FOR
/"\ 1 <. ANY 1 IV: p,~ v PFF1'nrl
Contractor: "-- c.. 'lt "'-n .......J . -, , '. ""
Address: '7 \ ~ f" ~-& \^- A '-'~
City: (;...... ~ '"-- State: () ((
Construction Contractors Registration#: fl111.. <1
Job Location:Llf CZl.
Assessors Map #:
Phone#:
Zip: C("1 Y.o ~
\0 I CJ"t
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Expires:
By signing this pennit/applicat!on, I agree to call for an inspection(s) as required (726-3769). I state that
all infonnation on this application/pennit is correct and that I was provided with the Wood Stove Safety
infonnation 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 Qualitx the Federal Environmental Protection Agency and I agree to provide the testing
approval 'Iumb spector at the time of inspection. I also understand that if I am requesting a
prelimin' , the wall covering may be required to be removed.
I /?..t; /0{ '1
Date' .
FOR OFFICE USE
REQUIRED INSPECTlON(S): WOODSTOVElPELLETIINSERT
Date of Application: 1/ ,,' / 7'i Job #:
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Total Amount Collected: 2{"ZA, Receipt #: ~ 32.? r7
PRELIMINARY _
17/}/~7_
Issued By:
dIP....;'
Checked for Delinquencies:
Checked for Historical Status: