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HomeMy WebLinkAboutPermit Mechanical 1994-11-7 . .... . . 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 ~ 1 ~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"{' ') ~L. . ~. administrati've 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 ....- / 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. -t- ~jkJt. JJ 3:qL( . . ~=~~=~1Yg~~f!:;~;~=\D.~~ REQUIRED INSPECTION(S): VOODSTO~LLET/INSER~ ~ PRELIMINARY Date of Application: \\-'1.qLt -- Job 11: q4\~1)S ~lo .9.0 .~ Total Amount Collected: Receipt 11: \ ~~~ ~ Checked for Deliquencies: Issued By: ~\~ Checked for Historical Status: