HomeMy WebLinkAboutPermit Mechanical 1993-10-19
\/000 STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LIN~/26-3/~
Job Location: .c;r;;; 05 (7 (fJ.-.t.-I'fY J;:rV,
Assessors Hap #: \"" C(na~ \
.D lit: D
Owner:I)06ser R lj) i.y~1l
Address: 043 b,(,4{UE,0 j)i{,
Cit,^,,-.Sfe/lUfS ?/Ef,J) State: oE.
Value of \lood Stove/tllet StovdInsert:~YK c2.:!5 C;Z J.7 0
(please cirCle appropria te a'i>Pi~"u,,")
Tax Lot
#: ()~(~rD
m. ./P4A--/
I
Phone #:
W7.i1/- ";;'767
Zip: 77 Lf 77
state surcharge.
(615
B~
Construction Contractors
State:
~
Phone #: J9j - ()~-33
,
Zip: q / L./ I) 'I
, ..... ..
Expires: /0 - ,;;2.6 -93
Address:
/ a.-rb-
City:
'-'" ~
Registration #: Lf&,c:;()r;:-
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 \lood 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~~= to;;;~moZ)~ If) J /9/93
~ure U Date I
FOR OFFICE USE
REQUIRED INSPECTION(S): \lOODSTO~T/INSE~
Date of Application: I D~ / ~...- '1 S Job
Total Amount Collected: (j};'L/D, 15
~PRELIHINARY
#: t/:=s /5"'Q7
1/
Receipt
#: / D~q
Issued By:
---------
j( j f) j} ;J!tU.-l-
Checked for Delinquencies:
Checked for Historical Stat~