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HomeMy WebLinkAboutMiscellaneous Application 1994-10-28 "- .'. .. .' ~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 ~ , , ' ( Assessors Map #:/7- () :2 -33 _. 3 ~ Owner: 7t3kL!5'rA- i C::;A~---~ 1/~~ (. I ~ ~~ fd// Address: .c::;~,.... Tax Lot#: (i)~1 1:2. :$ .. ,#II '!!\ J .,- .d'.. -. (W) C-l;.1 - '-J f --.; Phone: *: ?4/ -7/2..r . .. ,.... 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) I - 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-- ~ - . 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. 1~ <--. -~.- Date /,O/2~~/j / I' T ======================================================================================= FOR OFFICE USE REQUIRED INSPECTION(S): ~OODSTOVE~~ET/I~S~ ~- /~hj4~ Total Amount Collected: -/6...2.0 Date of Application: Job #: PRELIMINARY. c?4/~ 'Jet " I I ( Receipt #:~52 ~~ . . Issued By: ~~- Checked for Deliquencies: ----- Checked for Historical Status: