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HomeMy WebLinkAboutPermit Mechanical 1993-3-19 (2) .SPRINGFIELD WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: /31 g ~ 1\~ vJ60IL Assessors Map #: \ 'lO 3 B () 3 ~ Sf-UNY ~~ 1 ? 7 f ()J tion- WOof) ~ ~dL_._ State: Value of \lood Stov~t S~Insert: J!;2,ooo tf'O_ (please circle appropriate appliance) City: (')J0 Tax Lot #: ()9,OcD \)H r ~ ~ Phone #: '7Lf7/3;Q3 Zip: q71f77 Owner: Address: Preliminary Inspection is $15.00 (prior to installation of insert) \lood Stove/Pellet/Insert Permi t is $15.00 + $10.00 Issuance +. $.75 Type of Inspection ReqUested: ~ ~J\ Q \.lA'f\ ~ Contractor: C\ X'd +)'- ~ ~~ Address: m It: - 6f 8 '0') - ;'f\ n ^ City: WQ~ State: l)()lJ( Construction cont\Jctors Registration #: ~ state - Phone #: '(o8-3~391 () Zip: q-wW . ~n. ~R.~ 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 \lood Stove Safety information for wood burning - appliances and prelimi~~ry 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 ~e required to ~e remove \}(/\~~ ~ ., lignature / II Date FOR OFFICE USE REQUIRED INSPECTION(S): \lOODSTOV Date of Application: (~. c:r - PRELIMINARY c., /'J q?ffilo~ .. ""-:-"" ----.,.... Total Amount Collected: Receipt #: f/?5q ,ued Checked for Delinquencies: \. " ~ ) , ) .... Sta tus:"-f) \ "\. - Historical