HomeMy WebLinkAboutPermit Mechanical 1992-6-2
SPRI.-FIELD
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
lJ6t>.
225 Fifth S.treet
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726'-3759
726-3769
Job Location: ~ 1,;)00 ~'jj('Y1 1J.f7 "/-;"6 ; Rei
Assessors Map II: r7D?-1 Cj DO
Owner: J},()ld~u..J; fl~llll1.lA,pd
Address: -,-~.2rYJ /-1/1 y,../,oYl A..p Idge.' fl",J
Ci ty: C C::::/I/p///CjJ}e t1 State: (('kc.
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Valu~of~ood StovejPellet Stove/Insert: J'I7?IJ
(please circle appropriate appliance)
Tax Lot II: {)t')7 Do
Phone
II: '74t,-990 jY
Zip: 97d77
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection ReqUested:' /i~f"\A~In(/<2-
Contractor:
~JVlQ;V
Address:
Phone II:
City:
State:
Zip:
Construction Contractors Registration II:
Expires:
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 Yood 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 ~equired .to be r~moved.
~ )U.&i.;'! IZM/V?a /V__P _ (, -d -'bZ
Signature Date
FOR OFFICE USE
Date of Application:
YOODSTOVE/ruuuu..~T
II; ~ 2- -1 2-
0.70
v--
PRELIMINARY
q 2tJ 77R
REQUIRED INSPECTION(S):
Job II:
Total Amount,Collecte~:
Receipt II: L(t~L/
Issued By:
CL~
Checked for Delinquencies:
~
_Checked for Historical Status:
--.'
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