HomeMy WebLinkAboutPermit Mechanical 1999-3-24
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WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
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/7039--'J.-1;
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Assessors Map #:
Tax Lot#:_J5 S () 0-
Owner: /n/W&..=-f; IWAUAoJ.J rlAl4A
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Address: &0 I /:J7' A~ J 0). oJ, Phone#:-Z-i 7 - 5' 74' n
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City: S AJ.tz.l State: rV .' ""c" -Zip:. "~., ii."z;z
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Value of Wood StovelPellet Stove/.lnsert:....-.~ . --~)(Please circ.lef1~~'il:1iiPP1ianCe)
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPellet/Insert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
Type of Inspection Requested: f"Zle-eJ72!!!.iJJ};; IAIM~~~~~ (I.o// k4i8'eTl]
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Contractor: /J1/~.\ ,."nN..ore9~~'ll\"le ore9~.r "A\ 10,-\\"1
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Address: / & 7 e A~:N ~7.en\6l' '~~tOU9\"1 O~~e ,!/1\61ij#'! ~ </3 -//.1/
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By signing this permit/application, I agree to call for an inspection{s) as required (726-3769). I state that
all information on this application/permit is rorrect and that I was provided with the Wood 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
approvall\umber to the inspector at the time of inspection. I also understand that if I am requesting a
preliminary inspection, the \vall rovering may be required to be ~moved_
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FOR OFFICE USE
REQUIRED INSPECTION{S): ~DST~ELLETIINSERT V'" PRELIMINARY
Date of APPlication:')/ .:2.~'9 ,7' lob #: 9 7' /,/) "5 '7 ?
Total Amount Collected: 20,2'.0 Receipt #: Issued By:
Checked for Delinquencies: -' / Checked for Historical Status: