HomeMy WebLinkAboutPermit Mechanical 1994-11-21
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: jqrt/ /J1C;rA-/i,}/
Assessors Map #: \ '1 0 ?)~'l k~
O"ner: OI4MELL ol !2&t.6c.cA .\ 0 l~I\JUl^J
Address: jCfl:{lf vYl~'TAv1<:;J..J
CitY:<::::;'D~.fI.)l.1=It=LO State: nl'l.
C ",o\- " 00
Value of \lood Stove~llet St? Insert: "2...'1q.)-
(1,-
Tax Lot #: n(O 1(Y)
Phone: #: I ~lo - 'Z.'ir\"G
Zip Code:
en I.fJl
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Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
d*
a mlnlstratrve
$.45
Type of Inspection Requested: ';:;,vt41..
Contractor: P A-l "H 11J~12~
\: '7" j
A- FrE/l r:/S-L.;v~t'Af1
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r"'A 1<;: 7":tU]C r, ~
Address: <;:) ("'" LLJII.. ~ D~
Ci ty: bJ(, lC~
Phone #:
("n-09u7
q)l{O"?.
I 'L.{ qU
State:
~
Zip Code:
Construction Contractors Registration #:..9~ '\ ~
Expires:
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 "as provided "i th the Yood Stove Safety information for "ood 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 "all covering
may be required to be removed.
~4'?fmM.r \: ~t=(I!l:LTI t=l', '"'I;uc tJou ..z I l'ict4
S~~U~~~JP. Date '
=::::t==================================================================================
FOR OFFICE USE
REQUIRED INSPECTION(S):, \lOODSTOVE/~y)INSERT ~
Date of Application: \ \ ._9 J\' q~ Job #:
~ ,\0 .7(J
Total Amount Collected:
Receipt #:lD,~'2--
PRELIMINARY _
O{\r00
Issued By: r\\D~
Checked for Deliquencies:
Checked for Historical Status: