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: