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HomeMy WebLinkAboutPermit Mechanical 1993-10-29 YOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION Owner: ~,-,'" '" '!<: ~"" Address: \\()D~ R,~A'" '''"' Uqb Office: 726-3759 \ \0 D1 ~ ~~ Y\f~ ~Y\ ,_cAr,sQESION LINE: 726-3769. ~ Job Location: "-::~',~Q. '0~o YQ\.\.",\ s,,\""''\Q ~ ~<;-~\ ~~ ~ Assessors Map #: Ii /)'), ;)-~ 3,;::1 Tax Lot #: /'':)OD - . ~~,"".-' ~\\O 225 Fifth Street Springfield, Oregon 97477 Phone #: '\A\.O - \1,'t.:S City: ":3,~\'-~",--t~.\:\ State:Me>-C>.~ Value of Yood Stove~Stove/Insert:~ \ '\ '\~~ e;::, (please circle appropriate appliance) Zip: ~ '\l-\'\ 'I preliminary~s $15.00 (prior to installation of insert) Yood Stove/ elletlInse Permit is $]5..00 + $10.00 Issuance + $.75 f?/UA.tM . . ~ /J II /J Type of Inspection Requested: J;/1Ut-~. ~P Contractor: 6 c:>od ~ state surcharge. . Address: Phone #: City: State: Zip: Expires: ~;}{P/q f 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. ~"'''~ '- ~ ~~~\...-' Signature , Construction Contractors Registration #: ;)(07 J;;r \\:)- Date d-.C\- '\"0 FOR OFFICE USE REQUIRED INSPECTION(S): YOODSTOV Date of Application: 'J-CJ 1)c,r q Total Amount Collecte: 4G Lib, 7.s- Receipt #: 1 () '~~ Issued By: Job #: PRELIMINARY q 3/ ~L/(j !/) U;;UlA~ " Checked for Delinquencies: _____________ Checked for Historical Status: q3