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HomeMy WebLinkAboutPermit Mechanical 1995-10-31 . . \100D STOVEIINSERT INSPECTION CITY OF SPRING FEILD BUILDING SAFETY DIVISION 225 Fifth Street Office: 726-3759 Springfield, Oregon 97477 INSPECTION LINE: 726-3769 Job Location: ~~S\oC)\OY\~ llQ(\\ ~\M,Q .venA Assessors Map #: I~TO? ~ Tax Lot ~ CXXO I 0Ilner:~~\\0 R. . \bDst-lllOf) ~_UQ[)'-Q~ Address:BS\~\ 0\)~ () f\ ~ .' Phone: #:::I2J(1'~~lO I City:~~~I7i. ~tate: M / Zip Code: Qi)4'70 Value of ~o(.\.s'tove/Pellet Stove/Insert; \\ r ) - Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + fee + $10.00 issuance = $26.20~tal,' Type of Inspection ReqUested~\ .I -"'" .' Contractor: $.45 M; M j '!)~Yf( administra) ( ~ Address: Phone #: City: State: Zip C;ode: Construction Contractors Registration #: Expires: 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/application is correct and that I lias provided IIi th the Vood Stove Safety information for lIood 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 preliminary inspection, the lIall covering ,r:b.:;:~_:'.~ ~.:11. 19Q5- ~ure Date ======================================================================================= Checked for Deliquencies: Checked PRELIMINARY ~ Job #: q ~\~\~~ I",.d ,J~(. . for Historical Status: FOR OFFICE USE REQUIRED INSPECTION(S): VOODSTOV~LLET/INSERT Date of Application: 10.8/.'-1:::5 \0.CO Total Amount Collected: Receipt #: \ GN...fl/