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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: