HomeMy WebLinkAboutPermit Mechanical 1993-8-23
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
.
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. .
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: ,~0 ++~
Assessors Map #: \ 'l D'd m4
Owner: brM ~~.J-h
Address: .S 3[;20 H--15M0aAk.s }2.&_
City: x--cvlJ~ State: [)f?-
Value of ~oo~ Stove/€~/In~~~ if I Y q , ~
(please circle apprV~L.aL~ a~p~~ce)
f2d.
Tax Lot
#: (X)~()()
Phone
#: 7'-flrr ()y~:2.,!_
Zip: fllL/1 S-
Preliminary.Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75
Type of Inspection ReqUested:fV-eJIIY! ~. f<-tAlol- Ds.e.r-.r-
Contractor: ~ ffi f,f- ~17)vtJ (l Yl/-v~,
f /) fcm X;' ;)-S D I
-BU6~
state surcharge.
Address:
Phone #:
City:
State:.1'J2.--
Y{oS-O$"'
Zip:
q7LJ ()B,
16';)/5.13
Construction Contractors Registration #:
Expires:
\
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 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
ma~:e:l: r~v~tfrr ;?;~ft ~.
. ~'gna tu~ (J . (fltt. 10r
FOR OFFICE USE
Date
REQUIRED INSPECTION(S): VOODSTOV~
Date of Application: d--3 ~.~ _ Job It:
Total Amount Collected: 4--f), 1",
Receipt It: ) I ?fb~llfYiLq Issued By:
I
Checked for Delinquencies:
v
PRELIMINARY V'
Q,,3 / .?5o
MJ j 1J/1~-L
Checked for Historical Status: