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HomeMy WebLinkAboutPermit Mechanical 1993-8-26 VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: to \ 7.n ~Lu~ S+-- Assessors Map #: 170Z-~U ::., ) Ovner: ~Ou.)Af1\.. L~rrT IJ.1LrTOU!.;;. Tax Lot #: c:s '--I 0 ('J Address: ~ I ZO MAIO " City: Sp,cU) State: r:'lR Value of Vood Stove6ellet Sto~/Insert: '"2....39, (please circle approprlale appliance) Phone It: 7t/eo - 11 17 Zip: q7lf7) * Preliminary,lnspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.15 state surcharge. - Type of Inspection Requested: 1-, t\JAL Contractor: r~,:: IJn'L,\ lO<\.H7-I20Cl"li\I\ J Address: <"-7"'- UJtl(&) ~ n - (") 'lil Zip: Q,467 III q~ I 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 correct and that I vas provided vith the Vood Stove Safety information for vood 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 vall covering may be required to be remov~ .r;~~~ ~~<'MT'~~L.&Y~Q lfi"'J'- tip' -.!J,lC. 1-lj~9J SIgnature I ' Date ' FOR OFFICE USE Phone #: City: (.::, IC EA.J c,::: State: rJll. Construction Contractors Registration #: '5:' '7 'ZL ("\ Expires: REQUIRED INSPECTION(S): ~SERT ~ 7' C; Date of Application: <x ~ _AD -- 1?:; Job #: Total Amount Collected: '1.h.1? PRELIMINARY q 3/ 2--, '1 Receipt ft: \ e-ol,? Issued By: ~ Checked for Delinquencies: ~ Checked for Historical Status: ~"