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HomeMy WebLinkAboutPermit Mechanical 1999-9-17 . . ^:r:r.r=I\ITI('lN:ClT"lgC I .aw (tol WOOD STOVEllNSERT INSPECTION I\:PPLlCA TlOI)I.j;'d by the Oreoo" ,;. 10lIow rUle" au<<" v ' 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 __ ..:_.".. ?,t')': . \ fr20 ' t11r: 1112 trC ~~ jJ WvV 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 j- l' 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. t 225 Fifth Street Springfield, Oregon 97477 lob Location: I. (please circle appropriate appliance) '4 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 r;ff;;;:J:et{~:zu~tobefmoved. '1~ /~~ 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 qcy nS3cf Issued By: ~ I.iJ Jrd--.. Checked for Delinquencies: Checked for Historical Status: