HomeMy WebLinkAboutPermit Mechanical 1996-11-25
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SPRINGFIELD
11000 STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth' Street
Springfield, Ot'egon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
-
Job Location:-L9.:2./ #~~ L,:z>
Assessors Map ~: l~o"3.~:k, YO Tax Lo t ~:
Ovnet': ~~r6f/ 1'r:-~/?/?76
Address: /~2/ ,A.?'E"""p'L::P {,;z:>. Phone: ~:
City: 5~Tc..z::,. State: .&?/1, Zip Code:
Value of <$fod S tovJ>'Pelle t S tove<(ii'sert~ ,/ Y.:p~
Preliniinat'Y Inspection is $15.00 (prior to installation of insert)
1I00d Stove/Pellet/Insert Permit is $15.00 + $,75 state surcharge + $.45 administrative
fee + $10,00 issuance ~ $26,20 total
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70//'8 53~
970/'77
Type of Inspection Requested: ~&?P?~YG 4;':J~'J--/'" . . .
Contractor: 1/7 /;',7> ~/~~ ~'~;ob _~ ~~.
Address: ~2/ "'5.e"'3 ~ Phone~: 7V/'/.Je6z:>
Ci ty: ~ State:,OA;. Zip code: ~'y <'0'
Conslt'uction ContractorsR~gistration #: /LJ35?'? Expires:
/=<.y""~ ~?
By signing .this pet'mi t/application, I agree to call for inspection(s) as required
(726-3769), I state that all the information on this permit/application is correct
and ,that I \Ias provided \lith the 1I00d Stove Safety. information for \Iood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing'meets smoke ,emission standat'ds as set by the Oregon Department of
Environmental Quali ty or the Federal Environnlcntal Protection Agency and,I, agree to
provide the testing approval number to the inspector at the time of inspection, I
also understand that if I am requesting a preliminary inspection, the \Iall covering.
may be required t6 be removed.
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Signa ture ' ....
IIIOIS/f'~
.Date '
=======================================================================================
FOR OFFICE USE
REQUIRED INSPECTION(S): CIlQODSTOvE)PELLET/<1'rrS~ Y PRELIMINARY,
Date of Application: //- '2 ?-~ Job #: 9b/7({!;:2...
Total Amount Collected: 26. ~<::>
.'Checked for Deliquencies:
Checked
Issued By: ~~
t'~ '
for Historic~l Status:
,.
Receipt 11: '2?~7
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SPRINGFIELD
11000 STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon
-
726-3759
726-3769
b.
7'1"177 .~
~: C>~~~ ~.
.-
97477
Office:
INSPECTION LINE:
Job Location: /RJ./ 1Yluzf",' of,., "I ,
Assessors Map ~: //!"tf:)7-::? li'- ~
Ovner: J11~ ~
Address: / r?;J/ 71~ ~
,
~ ..kl'iJ /);{I
. V ]?if
Tax Lo t
Phone: ~:
74/- ?S~~
0/7'177
Ci ty:
~/i~p~J
o~od StoV$YPellet
State: OJ!
S
Stov~ /L/tn, ~
/
Zip Code:
Value
Preliminat'y Inspection is $15.00 (prior to installation of insert)
1I00d Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + ~.45 administrative
fee + $10.00 issuance ~ $26.20 total
Type of Inspection Requested:
&eC/ A'7 "oh"'~ y /9!y. /7~
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~..:-<;:-.><-
Con nac tor:
Address:
Phone ~:
Ci ty:
State:
Zip code:
Construction Contractors ~~gistration #:
Expires:
By signing .this .permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on' this permi t/application is correct
and .tha t I vas provided \Ii th the 1I00d Stove Safety. informa tion for \Iood burning
appliances and preliminary inspection standards. I further state that the appliance
.1 am installing meets smoke .emission standards as set by the Oregon Department of
Environmental Quali ty or the Federal Environnrental Protection Agency and I agree to
provide the. tes t ing approval number to the inspec tor a t the, time of ins pee tion. I
also understand that if I am requesting a preliminary inspection, the \Iall covering.
may be required to. be removed.
1}~/ YIJ~J.~t-
Signature
1/ /;,s he,
.Date
=======================================================================================
FOR OFFICI.> USE
REQUIRED INSPECTION(S): ~OODSTOVE2PELLET~SER1:>
Date of I\pplication: Ir/'-~
Total Amount Collected: /c:;;--
PRELIMINARY -
y
Job #:
q~/ $""Gz
.~hecked for Deliquencies:
Checked
Issued By: .d~
for "istori~~l S~tus: .
Receipt II: ;<"3J~