HomeMy WebLinkAboutPermit Mechanical 1994-8-24
.
.
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Loca t i on: ''1.~(o --!"LA-}lli S'I.
Assessors Map #: \ 1 03:A \ ~
Owne r : P L-11..D.bD. f\-. -t- f?t:,(I"rf-.::('
.....\,{A.'''lEoS
Address:
AS.
/l.-&:N c
Office:
INSPECTION LINE:
726-3759
726-3769
CPr::Lb. ("le.... o,lvll.
, Tax Lot #: mcx:xJ
Phone: #: Il.J../-'g 115
City: State: Zip Code:
Value of Vood Stov~~Stove/Insert: !){J.,6S
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 ~tal
Type of In6pec~n ~e(\qu~s.t~ ~ Moll ~ t - ~ S'm.N{ u\'\
Contractor: \ H...LJ \L.)[
Address:
City:
State:
Phone #:
Zip Code:
Construction Contractors Registration #: LKo~c:;
Expires: IO':"2.$-"1(J.
By signing this permit/application, 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 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 be required to be removed.
~~
Signature{J
M~LJ
d
1-CB--<1<J
bate I
=======================================================================================
FOR OFFICE USE
REQUIRED INSPECTION(S): ~O~D~VE~/INSERT )(l
Date of Application: (J ()I.., .~ Job #:
Total Amount Collected: Alo.9-.0
Receipt #: \~ (J
Checked for Deliquencles:~, ~
PRELIMINARY
Li4\ Hnt'')
Issued BY:~~
Checked for Historical Status: ,n
\.