HomeMy WebLinkAboutPermit Mechanical 1999-9-8
.
.
WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Job Location: 6 q 7 Ik tz-Io w
Assessors Map #: /10 3 2- 7 I "2-
Owner: L& /Z e tV /rI ( jt:t< I/J
Address: 6. r 7 I-/rJ tt-!o kJ /
SI) t 101
. ,(t/
. Office: 726-3759
INSPECTION LIN~26-~
-
Tax Lot#: 0 )t1/21)
tV
Phone#: 7Y6 :J.'&.fll
Zip: tj :;. 'f 7 7
City:
,
Value of~ellet Stove/Insert:
()pL
U/()(}.fS'lOvr:
(please circle apl"up.;ate appliance)
State:
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPelletlInsert Pennit is $15.00 +1. 05 state surcharge + $.45 Administrative Fee + $10.00
Issuance,
Type of Inspection Requested:
AJ~t>/ .r1:JVI:'
, leq\JIIl:lO:> yuu Iv
A1"l'ENflON:ureyUl ~,a~e Oregon UtilitY
follow rules. ad~?:e~h~"P. rules are set lorth
NotilicatlOl I ve' "-01 0 through OAM :J:>2-001-
in OAR 1>iigriQIf1-~+~;n ('noias of the ru\e~ by
OOIlO. 'IOU may- -- ,or (Note: the tele.1-l.no~
calling ttzf~gen!?;'nnn Utilitv Notlllcatlon
~ numoenu '''~'-1'-~OO_332-?31141.
. Cen\pr 15 . .
XI1lTes:" '
"'"
By signing this pennit/application, I agree to call for an inspection(s) as required (726-3769). I state that
all infonnation on this application/pennit is correct and that I was provided with the Wood Stove Safety
infonnation 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
approvall\wnber to the inspector at the time of inspection. I also understand that if I iun requesting a
preliminary inspection, the wall covering may be required to be removed.
~~~_Jf/ffi~~~. ' ~*~r
Sigilature . Date
FOR OFFICE USE
Contractor: ~W IV ~
Nu I j(,C:
A#m'Pl:Q~m!'lI-lAII I=XPIAli.1FTHEWORK
cWHORIZED UNDER~.IS~E~e~
CUIVIIVIt:I~IJt:U Ut'l,.:> HOM"JjJ.J,_u,"~
C~~egistration#:
REQUIRED INSPECTION(S): W,90DSTOVE/PELLET/INSERT PRELIMINARY
Date of Application: r/fi/r1 Job#: 1912.2--'1 . /J
Total Amount Collected: 2'. s-z; Receipt #: n3S 0 c..; ~ Issued By: # t);t-J/
Checked for Delinquencies:
Checked for Historical Status: