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HomeMy WebLinkAboutPermit Mechanical 2000-01-14WOOD STO VEIINSERT INSPECTTON APPLICATION CITY OF SPRINGFIELD COMMUNTTY SERVICES DIVISION - BUILDING SAFETY 225 Fifth Street Springfield, Oregon 97 477 SPRINGFIELO Office: 726-3759 INSPECTION LINE : 7 26-37 69 CITY OF ONEGON Job Location' qq{ A,Vqa,.rhe.,-: Assessors Map #Tax Lot#1n4*ry,, :-T- K.a*h,rtwa S*e-,^ror* Address:(.lver v le u^.-)1 lalZ d State: O z5,0C^(please circle appropriate appliance) Preliminary Inspection is $ 15.00 (prior to installation of insert) wood Stove/Pellevlnsert Permit is $ 15.00 + t .o5 state surcharge + $.45 Administrative Fee + $ 10.00 Issuance. Type oflnspection Req,uested: Ngql i rr.rsanr*t^l el<srt,r.nq- b.r.l-Lt Contractor; Address: share Er<ha.rs* 1 z<o't 3 6z Ciry:U<5 !r'Ott State 6R q7 Ll zG Construction Contactors Registration#: 5Z 3A(/o 240 By signing this permit/application, I agree to call for an inspection(s)as required (726-3769). I state thatall information on this application/permit is correct and that I was provided with the Wood Stove Safetyinformation for wood burning appliances and preliminary standards. I further state that theinspectionappliance'I am installing meets smoke emission standards as set by the Oregon Deparrnent ofEnvironmentalQualityor the Federal Environmental Protection Agency and I agree to provide the testingapproval number to the inspector at the time of inspection. I understand that ifI am requesting apreliminary inspection,the wall also covering may be required to be removed. Siguature q do Date FOR OFFICE USE varue o orr-o\trs,#*uo stovdh REQUIREDINSPECTI.N(S); WooDST.VE/PELLET/INSERT -PRELIMINARY A\ Date of Application Total Amount Collected ^oo Job #: ipt #:Issued By: D =d-r c= =iDD7J 12 BITEt= c-{ ;;,ii=E**J+*c) Hnc I;r'8H()acr. cf, J-D> cum Checked for Delinquencies Rece Checked for Historical Status (}oL'l