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HomeMy WebLinkAboutPermit Mechanical 1991-11-6 VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth S.treet Springfield, Oregon 97477 Office: 726~3759 INSPECTION LINE: 726-3769 Job Location: IR4- t\Th m~ ~1-W\ Assess~ap 1I: \~f),t 0~\~- Owner: \--'{ \ \ ~ \.i Jf\ 9, .~\ ~'f\ a e) Address::-lr1, '\ t\(), f\ilQ~ Ph,", .,l4i-ffi"">.=<' City:. ~J\l '-LDci State: (\Jl ~~\Y1J Zip: Ch4 ( / Value of Vood Stove!. e Stov Insert: \ c:!-J m. (please circle e appliance) Tax Lot 1I: ( )4-rcY) Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state sur~rge + $\O.?O Issuance. Type of Inspection ReqUested~_S\-o.Niinf) \h ~t \ . \ . Contractor: \.. Q {'(' n . }_(\ 0t\'\\(\\tY\,\'O [)) Address: 4\nS 0 f\bl1 ~ l\-f[1_ ~hone 1I: ?41:-SIS7 City: rJ DJ n Q State~ Cili 0 ~BVLziP: C\14D I Construction Contractors Registration 1I: 04-?\C;S Expires: ,/ /q Q / ,- 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 Vood 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 also understand that if I am requesting a preliminary inspection, the wall covering may ,;\>e r~d /'J,to.l b:-;emoved. YI ?(JG(L./~ /(/ G / q 1 si3qa ture Da te (, ( l\ FOR OFFICE USE REQUIRED INSPECTION(S): VOODSTOVE~NSERT V Dat~ of Application: \ \ Co (.\ \ Job 1I: Total Amount Collected: ~f=) .f)~ n . ~~ Issued By:(3){m )( PRELIMINARY q \ \?{'}\ I ,. i , Receipt 1I: ~ f Checked for Historical Status: ~ Checked for Delinquencies: