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HomeMy WebLinkAboutPermit Mechanical 1996-11-19 . .' SPRINGFIELD UOOD STOVE/INSERT INSPECTION.APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 - Job Location: /2-'/7 . )~i,;.'i/~ /70-3-3 Cf2X /~ .("en /-I/f? /75 . ~7';- '5"ur;,... h'l'// , , Uood Stove/Pellet Stove/Insert: Tax Lo t r,: rrJ:21 ?5 Assessors Map ~: Ol.lner: ,1{;;H~i< Address: Phone: g: 7'7/-:16~5'- . 97..,1'? City: State: bI/l. /, / IIi) Zip Code: Value'of Preliriiinat.y Inspection is $l5.00 (prior to installation of insert) Uood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + fee + $10.00 issuance = $26.20 total Type of Inspection Requested: ~ ~,45 administrative Contractor: Mt'~~ i34'''~/"} /'Z?5 /h...-t m-- 5/;~// . J;.lt'6-1z/'wll~ Phone ~: 7Y'/-? rJ' ..),.- Address: CTX- Construction Contractors 'Registration ~:~ Expires: /~f By signing .this 'pet'mit/application, I agr~z.-,f"tall for inspection(s) as required (726-3769). I state that all the information on' this permi t/applica'tion is correct and .that I vas provided vith the Uood Stove Safety' information for vood burning appliances and preliminary inspection standards. I further state that the appliance I am installing' meets smoke .emission standanJsas set by the Oregon Department of Envi ronmen tal Quali ty or the Federal Envi ronn,en tal Pro tee t ion Agency and I agree to provide the. testing approval number to the inspector at the time of inspection. I also understand that 'f I am requesting a preliminary inspection, the vall covedng. ../ b, ""h',d " ~ . \/ //77-7-" :S-7' /"" . ~ ~====================~===========~~~=~~~;~~;~~=;==========================~======= Ci ty: State: Zip Code: ? .?y7;? REQUIRED INSPECTION(S): Date of Application: {- LET /INSERT Total Amount Collected: ,.., 2h,:J () Job ~: PRELIMINARY,. 9b()tflfn Receipt II: 23glf? .- Issued By: ~ '"Checked fot. Deliquencies: Ulccked' for' "istoric~l Status: