HomeMy WebLinkAboutMiscellaneous Application 1994-10-28
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 4~() 7 ' /)/h<;: U ~
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Assessors Map #:/7- () :2 -33 _. 3 ~
Owner: 7t3kL!5'rA- i C::;A~---~ 1/~~
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Address: .c::;~,....
Tax Lot#: (i)~1 1:2. :$
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Phone: *: ?4/ -7/2..r
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City:
State:
Zip Code:
Value of ~ood Stov~le.0Stov~ ? ~cC90 ,oe:J
Preliminary Inspection is $15.00 (prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested:_ 'ifls-l71Jiafi?'J7/1 (D-t.tt4 (}I($e,f)
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ContraCtor:R~#1Y~r L-PC~L~JltA'/~A':s- ~r ~~-r ~/c:.
Address: ,P...p Ci--'x- ~ 4c"~r~ , Phone #: 1I!3~'3-"3"=</i!::>
City: /!F>~Ci:j-g- State: ~~ Zip Code: ~)Y'e:::>~
Construction Contractors Registration #: Vb~S-Expires: /.::?--::? dP.....;ii?.s--
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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/application is correct
and that I was provided wi th the ~ood 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 required to be removed.
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Date
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FOR OFFICE USE
REQUIRED INSPECTION(S): ~OODSTOVE~~ET/I~S~ ~-
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Total Amount Collected: -/6...2.0
Date of Application:
Job #:
PRELIMINARY.
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Receipt
#:~52 ~~
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Issued By:
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Checked for Deliquencies:
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Checked for Historical Status: