HomeMy WebLinkAboutPermit Mechanical 1996-1-26
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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Assessors Map #:-.I$~~-t::'.<-::?O
Ovner:. \/d? .HLf/~'?=?/ 6& _ '5
Address: 7~ 7 F ?:
Ci ty: h~7?
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Value of Yood Stove/Pellet
Job Location:
?7'.
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Tax Lo t #: ~/"9~
Phone: #:
72'6-a/3' ;/
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State:
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Zip Code:
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Stove/Insert: ~~.
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Insp~ction Requested: ~ E~ ~~ -.?'::r.r..r = ~~-S~.J-C' ...
Contractor: /-f~A'~'/'/e ~~d"." - .
Address: 7'7<9'7'2 ~E'~A:;? ,.?1'.z:;> .
City: CV~~E: State: ~~.
Phone #: -68'/ -C!' -S-6?~
Zip C;ode: 977"'P'2
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Construction Contractors Registration #:
Expires:
By signing this permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/ap~lication is correct
and tha t I vas provided vi th the Yood 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 o-f
Environmental Quali ty 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
~uired 0 be re oved.
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FOR OFFICI> USE
REQUIRED INSPECTION(S): ~DiTOV~PELLET/INSERT
y
PRELIMINARY
Date of Application:
J-2h~
Job #:
95"~<.9
Total Amount Collected: ~~. ~~
'-Checked for Deliquencies:
Checked
Issued By: 4-,..;'5 'Z.... ~
for Historical~tus:
Receipt #: -z.,t!.? /9e.?