HomeMy WebLinkAboutPermit Mechanical 1994-11-7
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SPRINGFIELD
VOOD 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: 078yg MnI')O~ t)_'l'\\}I::::
Assessors Map 11: \'lD3t:02
Owner: ~0Ml"I \-b.(,~fL<:::"
Address: .::2R<l'K rv\nVl(,)~ hit'; \U'::::- Phone: 11:~ - "7-'1r::);:::;
City:~-CiP Irl ;tate: ()12~/f,,1 Zip Code: q7l/77
Value of Vood Stove/Pellet Stove/Insert: AJJllDO ~
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~Preliminary Inspection is $15.00 (prior to installation of insert)
J Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45
fee + $10.00 issuance = $26.20 total
. Tax Lo t 11: a \('f"{' ')
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Type of Inspection Requested:~~\. \.Q...\ ~"'~
Contractor: '\\.O~~--\,('r:"\~ tf\ 0 {) -t-J\f\~ C\~ f\U r
Address: ,::);:)S\ q(~~\.D~ Phone 11: "'l'El.o -di \ a
City: '(\\,""X\'r\ ~ V1r\, State: ~ . Zip code:CflUS<1
Construction Contractors Registration 11: YOBR Expires: 1- \::\-C11o
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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/application is correct
and tha t I ...as provided ...ith 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.
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REQUIRED INSPECTION(S): VOODSTO~LLET/INSER~ ~ PRELIMINARY
Date of Application: \\-'1.qLt -- Job 11: q4\~1)S
~lo .9.0
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Total Amount Collected:
Receipt 11: \ ~~~ ~
Checked for Deliquencies:
Issued By: ~\~
Checked for Historical Status: