HomeMy WebLinkAboutPermit Mechanical 1997-2-13
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: L/9/ /lh.d: oIrtJ./'< 1~fJ)Jld,()1!. Q7t.J77
Assessors Hap 1I: /7 c:J 3::> 2.. -, 4 / Tax Lot 1I: ,<) 2. ~ r70
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Owner: .fJ jiL 1/Y}/i'JI.h)
Address: J.t1/YYU /lLJ il'~~ Phone 1I: 7r/t,-FI3/
City: State:
Value of Yood Stove/Pellet Stove/Insert: C#;9.!Ju .00
(please circle appropriate appliance)
Zip:
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit' is $15.00 + $ ,75 state surcharge + $10,00
Type of Inspection ReqUested:~~~~~1 ~LlJl)~~~~~
Contractor: I9A(1 /I};/~/VJ"II ~J>.MI~'-'
PO, lJo-i logO
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Issuance.
City:
State:
nR.
7 :3J1O(<>
Phone 1I: Q37-g('/J
Zip: Q7cJ 3/
Expires: ~ /97
Address:
Construction Contractors Registration 1I:
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 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
may be required to be removed.
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Signature .. V
FOR OFFICE USE
:<-!~ - 17
Date
;" i
REQUIRED INSPECTION(S): VOODSTOVE/~.~L~l/IN~ ~
;;In 19 7 Job 1I:
/ ~.2..0
'2-4-)'6 i
Date of Application:
PRELIHINARY
<::J 7 tf:) 21.,
Total Amount Collected:
Receipt 1I:
Issued By:
-r~~
Checked for Delinquencies:
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Checked for Historical Status: