HomeMy WebLinkAboutPermit Mechanical 1999-9-17
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WOOD STOVEllNSERT INSPECTION I\:PPLlCA TlOI)I.j;'d by the Oreoo" ,;.
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CITY OF SPRINGFIELD , '''Mt; n Cpnier. TncFr ''''eF . rr -I .
COMMUNITY SERVICES D1VISION""lIBtJICDING.SAF,ET~\rolJo ,('lA~ ,;"...'
. in OAli ~O.<-UI""'V ",' , .. .
OOflO. You may obtain COP1E'~ ')1' . ',' .
calling the center. (:'\:0':' ,c" I" " - - Office: 726-3759
numbertorthe Oie:,o;, 0:.'1\ ,\INSRECTION LINE: 726-3769
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Assessors Map #: 11.. (J 2.. - 1 CJ Pa f!.r~j Jb:5 Tax Lot#: 0 t tj 00
Owner: C)~K ~ 6fl(J I ~&A6 / -r; Tr1 ~hA{ lJ .: rn~
Address: P. 0 _ Box ?-o 2- , 1 . Phone#: :r1./!J-S ~ Ii
City: c; -{)J~ . State: (JQ Zip: q 1I1J/K
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Value oftGlood Sto~ellet StovelInsert: j ~ q c:;
l" ".)" La " L;be:~ '
Preliminary Inspection is $15.00 ~or to installaion of insert)
Wood StovelPelletllnsert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
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225 Fifth Street
Springfield, Oregon 97477
lob Location:
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(please circle appropriate appliance)
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Type of Inspection Requested:
Contractor: Sb. tJ-l- IJJ}'111q~<NO-(~M~/,,~
, '"],~ THISPERMlTSHI-ILLB, :l~
Address: "7dCf......,. ~OI7r=n1J?llEliililJH\~~ 'Y/..l?fJ
City: <j -fJ/. State: 0f~MENCEDORIS.ABANDONl:l)t-un
r - . ANY 180DAYt"cf\tBE.
Construction Contractors Registration#: Expires:
By signing this permit/application, I agree to call for on inspection(s) as required (726-3769). I state that
all information on this application/permit is correct ond that I was provided with the Wood Stove Safety
information for wood burning applionces ond preliminary inspection standards. I further state that the
applionce'i am installing meets smoke emission standards as set by the Oregon Department of
Envirorunental Quality or the Federal Envirorunental Protection Agency ond I agree to provide the testing
approvaln,umber to the inspector at the time of inspection. I also understand that ifl 8m requesting a
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Signature . , Date
FOR OFFICE USE
REQUIRED INSPECTlONf): WO?DSTOVElPELLETIINSERT
Date of Application: Of I /1/ q1 Job #:
Total Amount Collected: '~.51 Receipt #: 0 '3)~ 00
PRELIMINARY
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Issued By: ~ I.iJ Jrd--..
Checked for Delinquencies:
Checked for Historical Status: