HomeMy WebLinkAboutPermit Mechanical 1994-5-27
VOOD STOVE/INSERT ,INSPECTION APPLICATION ' ~;V'
CITY OF SPRINGFIELD ~
BUILDING SAFETY DIVISION '12.AI.phsAuA.. OJ,
225 Fifth Street
Springfield, Oregon 97477
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Office:
INSPECTION LINE:
726-3759
726-3769
.::::::::..-
Job Location: q 3'-\ 0 (y 'v>'-e ~c
Assessors Map II: \ f") r-s::Q ~
Owner: ~1) h Y\ ~he..vr'--\ 7~eY\ ILl n...~-e.{
Address: ~'1 L/ c) LLJ ~p Ie.
City: ~~ State: ()(
Value of Vo~d Sto~e/'ellet ~~ cl2C() pO
(please circle appropriate appliance) }
Preliminary is $15.00 (prior to installation of insert)': \rs~ '\S
Vood Stov Pellet/Insert ermiKs $15.00 '" $:O~OO ~suance + $.'15 st;te surcharge. T.
Type of Inspection Requested\ Mo\\d- ~ -cilo,~O
) ~i!-- \\ luhrnn(l ~~(\ Jl.
Mcq () Phone II: lorB. '"
;ate: ~ J Zip: ~,
4-1.o~ EXPires:-LJ).~.CfT
Tax Lot 1I:
(I}\q 0 I
Phone II:
1\.{.( -00/9
Zip: crt\{ 11
Contractor'
City:
Construction Contractors Registration II:
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 bj ~equired to be.removed.
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Signature iJ () Date
FOR OFFICE USE
Receipt 1I:
Collec ted:
\"b\)':0
VOODSTOVE/~~T/IN~') ,~ PRELIMINARY
~ &~ .C{1 --:'ob ~: q4f)~
6tVJ.9U
REQUIRED INSPECTION(S):
Date of Application:
Issued By:
~~
Total Amount
Checked for Delinquencies:
Checked for Historical Status: