HomeMy WebLinkAboutPermit Mechanical 1999-12-9
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WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
/1J,gs;- L~~.
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Assessors Map #: /~102 /?/-, l'<
Owner: ~T~ 4~~
, .11 ~
Address: /O~- --< ~ ~
City:~..~ State: (f2p
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Value of ~ellet StovelInsert: ~O
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPelletlInsert Pennit is $15.00 + 1.0:;' state surcharge + $.45 Administrative Fee + $10.00
Issuance.
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Tax Lot#:
Phone#:
'7 c/i/. 2-1 ~ ~
Zip: 9"? rt 7 %"
(please circle appropriate appliance)
Type of Inspection Requested: A;JTl((tI~
O'j,(/~.
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*
Contractor:
Address:
Phone#:
City:
State:
Zip:
Construction Contractors Registration#:
Expires:
By signing this pennittapplication, I agree to call for an inspection(s) as required (726-3769). [state that
all infonnation on this applicationtpennit 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 Quality or the Federal Environmental Protection Agency and I agree to provide the testing
approvall\umber to the inspector at the time of inspection. I also understand that if I am requesting a
y pr:Y2ary inspection, ~~be required to be removed~ 7' 1<7'7'
Signa~ ~. Date
FOR OFFICE USE
REQUIRED INSPECTION(POO~ELLETIINSERT
Date of Application: /2 - 5' - 5' 5'
Total Amount Collected: U,r:v Receipt #:
/" PRELIMINARY
Job #:
ClC}/i'-C-;;
Is~ued ~y"'_(/~
-SC, 3' ~ .J
Checked for Delinquencies:
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Checked for Historical Status:
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