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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 .. 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 ,0 p/,i1o./L 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. eJ~ .JJUAJjrfJJJitI 'Iltntff/ Y)tlV1'.l1--7J7Ji 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: --- Checked for Historical Status: