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HomeMy WebLinkAboutPermit Mechanical 1992-8-28 .~ YOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION U6b 225 Fifth S,treet Springfield, Oregon 97477 Job Location: &.f~5 ~/~/ ~ Assessors ~ II: I f) 03'J~~ Owner: C::\Jer"-l -2 kef/If ~UI1I'1 Address: ,.;;d!.; 5 (j/-,{) red;uu ~ Ci ty:' \....'l./;/rd, - / Value of Vood Stove/Pellet Stove/Insert: '(please circle appropriate appliance) Office: INSPECTION LINE: 726-3759 726-3769 ,JJp/cL & 91A/11 I /TV) I) f""oI ) Tax Lot II: l rl.t( U Phone II: '1"// -J'..3 Jj;j. Zip: C/7'417 State: ~ ~ J~(), 00 Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permi~,.~$15.00 +. $ .75 state surcharge + $10.00 Issuance. Type of Inspection ReqUested~ \ 0 ~ 'l f'{\ Contractor: Address: Phone II: City: State: Zip: Construction Contractors Registration II: 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 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 o und and that i~~:d~equesting a preliminary inspecti~njY the/wall covering may ui I~o be r~t~U 1~8'192 SIgila tIre' : "j-, Da te '- ~ FOR OFFICE USE Receipt II: Collected: lo~ _, A ~PRELIMINA~ 0),~.q!:L . Job II: -q cG \\qL1" \~OO _ Issued BY:~(_~ _ ~ VOODSTOVE/PELLET/INSERT REQUIRED INSPECTION(S): Date of Application: Total Amount Checked for Delinquencies: (jl ( Checked for Historical Status: ~ /' /