HomeMy WebLinkAboutPermit Mechanical 1999-02-16CITY OF OREGON
Iil/OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION. BUILDING SAFETY
225 Fifth Steet
Springfield, Oregon 97 477
SPRIi.GFIELC,
Office: 726-3759
INSPECTION Lll{E: 7 26-37 69
Job Location:
Assessors Map *:l)^X11 a/Tax Lot#: U /
Owner:
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in OAR 952-001
0090" You rnaY
ATTENTION
fol low rules adoPted by
Notification Ce
-0010 through
Type of Inspection Requested:
(prior
is $15.
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puone*: a ),C, 76 -1o
1
State: f f-
ACl {!t (please circle appropriate appliance)
to installation of insert)
00 + g .75 state surcharge + $.4+0&dil$ffitive Fee + 910.00
Lt ^.
THIS PEHMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDEH THiS PERM ff IS NOT
c0 MMHNCES OR iS ABANDONED FOR
Contractor:/'l ,/" /;; i IorJ -7,
Phone#:
City 2nr^o-o State:lL/
Construction Contractors Registration#: Expires:_
By signing this permiUapplication, 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 Wood 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 qumber to the inspector at the time of inspection. I also understand that if I am requesting a
inspection, the wall covering may be required to be removed.
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FOROFFICE USE
REQUIRED INSPECTION(S) :
Date of Application:Job #:
Total AmountCollected:
L/ l, U #,03L861
PRELIMINARY
f?r .-z
Issued
CheckedforDelinquencies:-CheckedforHistoricalStafus:
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