HomeMy WebLinkAboutPermit Mechanical 1992-4-3
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
J6D
225 Fifth Street
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
Job Location:
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Assessors Map 1I: \ '1 () ~ Q~ ~ 3
Owner: U/1;r/ ft, itJMLtrr
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Address: /50 & /lIU./J"L to Loop
Tax Lot
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Phone 1I:
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97'-17 7
Ci ty: t;..."AP,,(. State: 8k-
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Value of Vood Stove/Pellet Stove/Insert: 1{1?1S~- *
(please circle appropriate appliance)
P'oll.'.'<YJ!'!o.,H~ " 'is.oo (",., ,. 1.,,,'''''10. .f to,.H' . '. .
Vood Stove/~llet/Insert P~ is 15.00 + $ .75.state surchar,ge + $10.00 Issuance.
Type of Inspection Requested:_ ' _ I \..~.A..Dhm"'t Lf\..~
Contractor: Cr-a.1J1- SJtrz/(J
Address: \8!c:) \J'J \.o-\-t\ A_~ Phone 1I: 4<6:S-0CS ~
. City: Y J... 'Y1~ State: (eye.-/ Zip: q14-O?_
Construction con~actors Registration 1I: ~..Q ~ _Expires: '\(). ?...R.G( V
Zip:
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 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.
~ .(L.-/~ -tt'./~~1I
~nature "jI ':7l>"f
l" FOR OFFICE USE
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REQUIRED INSPECTION(S): VOODSTOVE~INSER~ ~ PRELIMINARY
Date of Application: 4~.q1)'/ Job 1I: QQ()S5L-
Total Amount, coll~~.~ ~ ~ d I
R.,o1" t. I'lli'> ,')f.o"Y' l~yri1-;
Checked for Delinquencies: C-jI' Checked for Historical
I
Date
elt.o351-
Status:J,;J
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