HomeMy WebLinkAboutPermit Mechanical 1995-9-6
.
.
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location: 70b //'/7;?7//lO/J
Assessors Map #: l-r 0 ~ '3 "=t I L
Owner: /:"()(/Jf>.- Fa5kK
Address: /(")h /.//7/??// /0/7
City: r C/~ State:
-J
Value of Vood Stove/Pellet Stove/Insert:
on.
/ /on
Office: 726-3759
INSPECTION LINE: 726-3769
Tax Lot #:
Q(t7~
..
Phone: #:
70'-:22S9
97V'77
Zip Code:
Preliminary Inspec t ion is $15.00 (prior to ins talla tion of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: O.rJi'M/ l?J9tlV
Contractor: cr4/! ..sToVe .
Address: / f?ZS u (,7J
Ci ty: CcI5f!7e.-
State:
ore
#: L/t~a5
Construction Contractors Registration
Ins-P
Phone #: I/J?S-n.533
Zip C;ode: 971/0-:2..
Expires: /0-:22- 9s
By signing this permi tlapplication, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/ap~lication 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 Quali ty 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 preJjminary inspection, the wall covering
ma~:A:o b~ AA- 5?- 6- 9s
S~ature . Date
FOR OFFICE USE
ccc====================================================================================
REQUIRED INSPECTION(S): VOODSTOVE/~ET/INSERT
Date of Application: g ~ (P-Cf,
Total Amount Collected:,,1/, IS. OD
ReceiPt#:DIKCf37 ",
Checked for Deliquencies:
~
Checked for Historical Status:
Job #:
PRELIMINARY
qSI450
Issued By:
"
~