HomeMy WebLinkAboutPermit Mechanical 1998-1-21
'.
WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Job Location: ; Z 5f.J HA/>1" 10 W sr
Assessors Map #: II D3 3 "r :J.J. ()[) ;I;).,
Owner: LidNA: J3t2.4;JC#
Address: / t 5>7 II ;9;17/'- rt'r-' .s.r
City: .5P;'?/r/~/L:LP
State: 6R
Value ~ood Slov~ellet Stove/Insert: Il If U)
.'
c:
-f
:J:
o
:0
~'; N
':" n1
t:J
'\.)
~~l () S;
+," .n L
Office: 7.2.~-?Z5~?,
INSPECTION LINE: 726-3769D
co -f
'f> T
"" ,-
OW
OJl
iii.J.J
oS:
Tax Lot#: ..., -f
Ow
:Oz
o
-f
:r:
en
"
m
2?
::,.
=i
w
I
)>
r-
r-
m
x
3!
:0
m
"T1
-f
:r
m.
:l:
o
:0
;:0:;
Phone#: 7t..6 ~ /(,85'"
Zip: 971/77
(please circle appropriate appliance)
Preliminary Inspeclion is $15.00 (prior to installation of insert)
Wood StovelPelletlInsert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
0-' Z
'" 0"'09.0):1:
coco :;:=-J
3 !!!.?)>o'O-1
C'""-<:xl,,,::Em
m~oco=...z
0.... cUlO5..-J
-- 1\):;] CD-'
rn o::r3 ' 0'" 0
-' I(D 0
-- Q)OmD)2'
CD::rO'<.....~o...
~,<O<Oo'_oO
-. :1 0 m
:.. u-c:ro..."Sm
~...mS'-". coco
Coco ~ -'o~a.o
_<C_='_~ ::J
o....Z(')::ro~_.
I ::Jooacn tu
Construction Contractors Registration#: Expires: ~ ~ ~ ~'.5 ~ ~ ~
.=:fcn::r-O(t)
By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state ~~ ~ ~ ~ : ~ ~.
all information on this application/permit is correct and that I was provided with the Wood Stove Safety g m i6 :xl a; g r;
information for wood burning appliances and preliminary inspection standards. I further state that the g -g. 2 ~ ~ c q
appliance"1 am installing meets smoke emission standards as set by the Oregon Department of g. ~ ~ 6 a- ~ ~
Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing:> C' ~ ~ '< 0
approval 'lumber to the inspector at the time of inspection. I also understand that if I am requesting a '< ,
preliminary inspection, the wall covering may be required to be removed.
/
Type ofInspection Requested:
Contractor:
Address:
City:
State:
(Si~
~
FOR OFFICE USE
REQUIRED INSPECTION(S): WOODSTOVElPELLETIINSERT
Phone#:
Zip:
~a:;Z 1/9'
PRELIMINARY
Date of Application: I -.;2 \ -.::; Cj Job #: L:/ q () 14. LI-
Total Amount Collected:~. dO Receipt #: 21 J-Io 37..-- Issued By: coM l) .
Checked for Delinquencies:
'/'
Checked for Historical Status:
~"