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HomeMy WebLinkAboutPermit Mechanical 1995-11-20 ." . . 1I00D STOVEIINSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 ... Job Location: ~~"9 .h-?A-#,pA' Assessors Map #:. /?-<'~"-:?"7-7 3 Ovner: '1VrAc-y ~ S-b4 S,\M~ Address: "2-lob'1 M~or 'Drille... City:, SPviV\o:/J,dd. State: Value of 1I00d Stove/Pellet Stove/Insert: 7!A-. " " Tax Lot #: ~c:>B~ Phone: #: iLf4-1D02s' 17t!T7 o~ -:11 ~CYO Zip Code: Preliminary 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 = $26.20 total y,JJJ-- (l-I'iVt- Contractor:/I(~/7L?Lf.V.AfC 5;,..,...~ ~..r-./~'5 Pc:J-~X 21/<9'/6 Ci ty: EL/Vi~~ Type of Inspection Requested: State: ~A. #:Yb~~ Phone #: ~ - =3' :?/~ Zip Gode: ~;>~~ /.:::::'-~-9'~ Address: Construction Contractors Registration Expires: By signing this permi t/application, I agree to call for inspection(s) as required (726-3769). I state that all the information on this permit/ap~lication is correct and that I vas provided \lith the 1I00d Stove Safety information for \lood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quali ty or the Federal Environmcntal Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the \lall covering :~::;;; ,L''Od 1/-20.15 Date ======================================================================================= FOR OFFICE USE REQUIRED INSPECTION(S): 1I00DSTOVE~T/INSE~ ~ PRELIMINARY Date of Application: 1\' '2.-O.~S Job #: 9~/$/o Total Amount Collected: --26.::2.~ Issued By: 4~ , V" Checked for Historical Status: Receipt #:~":?'? '-Checked for Deliquencies: