HomeMy WebLinkAboutPermit Mechanical 1997-1-17
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SPRINGFIELD
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VOOD STOVE/INSERT INSPECTION .APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth' Street
Springfield, Oregon 97677
Office:
INSPECTION LINE:
726'-3759
726-3769
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Ci ty:
./ Value
Job Location: \51-\0 \-{d\ oS S R~.
Assessors Map g: \ -::t-a ~ '?-.'-\ ~ -Z-
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Address: . \ ~'-:\ a \,ze.. \ \ Clj ~ R tk .
'S.~r~f'\J-S-e...\ 6.... State: C'lR.
of Vood Stove/Pellet Stove/Insert: 2 ~_ 6-b
Tax Lot ~:
Dc)~CJ(J
Ovner:
Phone: #: ( S'1 \\ -:::t.;1. In - cl 0 I{ C)
Zip Code: q"=\-~-=\"=\-- ~'S~\o
Preliminary Inspection is S15.00 (pl'ior to installation of insert) ,
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.65 administrative
fee + $10.00 issuance.= $26,20;otal /, .=--......: -Z:-....... ~ ""-
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I Type of Inspection Requested: r~-= ....;;..~i, ,':::-;. ~.J':"5 _, V".2:",
Contractor: \{e....~~ Le.e....s~()..,.{"""\ \ Le...e.....<:;.Y'n~ ~<;.\-v-v-,..+.. ~
Address: <l ~ S r\. <;(~ Phone #: 9 q S -lo \ S=t-
City: \--\-o....rr..<::.bura State: nR Zip Code:. S-:}\4'-\lo
Construction contractodRegistration' #: '::\-"l O~d.. Expires: ~\ \ \C\-=\-
By signing ,this 'pel'mi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and .that I vas provided vi th the Vood Stove Safety. information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing. meets smoke .emission standard:; as set by the Oregon Department of
Envi ronmen tal Quali ty or the Federal Environn,cn tal Pro tee t ion 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 prc:J.iminal'y inspection, the vall covering
may be required to, be removed.
~CA~~Q .':1-~~.
Signature '. - D
Da t~ \ \ ':\-\<:1-=\-
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FOR OFFICE USE
REQUIRED INSPECTION(S): (1iOODSTOVYPELLETlINSERT
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PREliMINARY, ,zz...~O-<)\.Z
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Date of Application:
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Job #:
Total Amounl Collected: -:;::,0' <~
Receipt 1I:~ ~~
Issued By: ~~;
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Checked [or' His Lori,cal t(sta tus: .
'-Checked fOL Deliquencies: