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HomeMy WebLinkAboutPermit Mechanical 1993-4-26 VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: I \~, I i'J11()FI 1-10'= Assessors Map II: \ Pi'A[){ 0 \~~ - - I Owner: b~ () {MI4.(.J;41l . \ CAJKIAl'\ Address: -1.1 ~ ~ LAIlRt--:!- Aut= City: ~otZ'A.\l' '::,F( Y\ State: Value of ~OOd StoveAfe;let Sto~~nsert:) (please circle appropriate ayy:~once) Tax Lot II: /()CCl(Y') nt7 z..~q\~ Phone II: ~-Z1 1 Z 7l/7-l'f)(" Zip: q )</77 Preliminary.Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75 state surcharge. Type of Inspection Requested: )=>e€..I1l"."6CJ 'I- FJJf.JA...!.. Contractor:. Lf:;,: ILl '.1 ('~AIS772'JC.~'&) Address: ~Q~- ~A_"I t:IIA I Phone 1I:~'i?'~-<'I~~ City: (::.,l',l'-AJf-::-- State: r>c Zip: q.,I./D;> Construction Contractors Registration II: S 77J~r"'" Expires: IIIq3 By signing this permit/applic~tion, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was provided with the Vood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the wall covering may be required to b~Lc"'~, f;'"'lG,L"'H \:<,"c:wc. &, ~ _ u 9" f/P~ JI t-/Jzee,/q \ SIgnature 1 Dat~ FOR OFFICE USE REQUIRED INSPECTION(S): VOODSTOVE~T/~ Date of Application: 4. 2-l r?'~ Job II: Total Amount COll:=~:$' 4tJ, f{ 0 . 1 Receipt II: ~~W Issued BY~ f\(f\/'. Checked for ~linqUencies: ~~.:: for Historical PRELIMINARY C( WS'2:R ~ - Status: