HomeMy WebLinkAboutPermit Mechanical 1993-10-29
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Owner: ~,-,'" '" '!<: ~""
Address: \\()D~ R,~A'" '''"'
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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
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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
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Type of Inspection Requested: J;/1Ut-~. ~P
Contractor: 6 c:>od ~
state surcharge.
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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.
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Signature ,
Construction Contractors Registration
#: ;)(07 J;;r
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Date
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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
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Checked for Delinquencies:
_____________ Checked for Historical Status:
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