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HomeMy WebLinkAboutPermit Mechanical 1994-8-25 , '. . 11. ~?:>l - ODGj OD SPRINGFIELD VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726_~~4~f',' , " 726-37, U" . ^ . ' Job Location: 70'3</ tY7~/Aj S'r:' 5fte.JAX.F"IF)..)) ~~. 97t./7~ Assessors Map #: rtR.<J.J SHJ-r7 /7 Tax Lot #: ac qf'\(') Owner: (?", J I Address: 71) 3 <I ~, l.A~601> (V\. A /IV 5 'f. Phone: #: 7tf 7-LJC1 0 / 97<172 City: :5fRJI,)t. Cltr~'P State: Ole Zip Code: Value of Vood Stove/Pellet Stove/Insert: -~~ Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $,45 administrative fee + $10.00 issuance = $26.20 total Type of Inspection Requested: JL/C1A) ~~l> C::;'7"T")tlC Contractor: $EJ.-F Address: 7D3t./ /Y'MoJ City: 5PJ!JAJ(,.'{)~J..."D $7": State: D/f!., Phone #: 7'17- 090/ Zip Code: 9?4'7'is ' Construction Contractors Registration #: Expires: By signing this permi t/application, I agree to call for inspection(s) as required (726-3769). I state that all the information on this permit/application is correct and that I was provided with the Vood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspection, the wall covering ~e~~:O~~ _ ~./CJ. Date-<=-). - /99/ ======================================================================================= ( FOR OFFICE USE Y. I Date of Application: Total Amount Collected: Receipt #: \bA\rb Job #: PRELIMINARY qq\~\)l () By:~tDc0 REQUIRED INSPECTION(S): Issued Checked for Deliquencies: Checked for Historical Status: