HomeMy WebLinkAboutPermit Mechanical 1999-12-3
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SPRINGFIELD
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Assessors Map #: 170322./ L-
Owner: f!Il(i.V'( COl/tO veV-
Address: (PI z. j()(c..L..o{a.s Or
City: 5 P'l""'j~~(c1
Or
5 PVC lAQl/oe/d
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130{;
Tax Lot#:
Job Location:
Value of Wood Stove/PelIet StovelInsert:
State: 0 ~
/300 !!!Z-
Phone#: 77""('- ??'?q.5
Zip: tf 7<(<' 77
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/lnsert Permit is $15.00 + I.oS state surcharge + ~~ Administrative Fee + $10.00
Issuance. (!!-odJ l.eJP( - !2e.V<:. V'~
Type of Inspection Requested: woooe s-bvc: (Vl5"'iI'T (1/I-;fa.I /a toto{"
Contractor: fUa5()11( 5wee r:x;
Address: '5///) }f/~7 /Ul7Pi-' fr-
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City: ~~;ru~ State: "",.7-3.
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Phone#: 33~ - Ya?7'
Zip: 9?'Ye:?.2..
Construction Contractors Registration#: I::> / c./ 7'7/ Expires:
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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 correct 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 8m requesting a
preliminary inspection, the wall covering may be required to be removed.
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Sigriatufe
Da/yy9Y
FOR OFFICE USE
REQUIRED INSPECTION(S):~ODSTO\ij;)pELLIf'RIN:~ERV V PRELIMINARY
Job#: q<9/t:;:::?7~
ISSUedBY:~Z
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Checked for Historical Status:
J=<~ "3~-?.,.
Date of Application:
Total Amount Collected: ~. 5e:::> Receipt #:~3;c:>g
Checked for Delinquencies: