HomeMy WebLinkAboutMiscellaneous Application 1998-4-15
.
t:
"
SPRINCFIELD I
, .-
\1000 STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth SUeet ~~~ Office:.' 726'-3759
Springfield, Oregon 974 77 Tl\t.~etTJ:ON LINE;-' 726-3769
" . ~~~'.. ~O\ , .
, '..... . 'I(0~ ~ .... \~
Job Location: S-2 y~ i)A)~~~~~~~~~~~~~~;~~O~
/1/\ 2 D ~ J"~~\ ...\\)t;;.Y' ~\)\J\, u. 0 If 1- 2 I I
Assesso r s Ma p :' /~ ::> j.~ \";;~~\) \)~",~ ~1!>1'l Tax Lo t ,. 'f III '-f .
O,vner:_~:: 'A~CL . 'rv.ell ~\)~~, ,~~C~\) #\(.~O\)., '
, '....' t.) '. , CO'\-l\\" "f\),~i' -', ' "
Address: ,S 24~ '_ AlsY ~J ,~\~ Phone:' ~';-7t.i(;,~'?~(~..
City: 'S,ptlJtJr.I=-/8-I{) .. . State: .~ ()~ZiP Code:. q74/1
Value ~f Uood Stove/Peliet, $tovelInsert: L~ Of ') . .
,.
, ,
Const,ruction ContI;actors 'Regi'stI:'ation ft: Oc, 77'L...}I
, ,
Preliniinat.y ~tion is 515.00 (pd9f to installation of. insert) ,
\lood Stove~elletjI~seI:'t Per~it is 515.00 +' $.75 state surcharge + $.'5 adminiitrative
fee + $10.00 lssuance = $26.20 total '
Type of InsPri tion ,ReQues ten -r::l' AL- (, ,I (' , . .
Contt-;actor: l~t.~DJ f/Il.t/Es;3SI 0 AJA-<. ~, ~)({.{-. ,
Addr~ss: 2-1-''' C J ~ 'r\. 4 J'e P'h'ne #:: If(l/- 9tr:n '
City: (~LX~ t=10E-, . Sta~e:_a ", ZipC;ode:Q74-0J'
C(j9Y.
Expires:
,By signing .this pet"mi tlapplication, I agree to call for inspect.ion(s) as required
, (726-3769). I s ta te tha t all the information em this permi t/applica tion is correc't
and .tha t I vas provided vi th the \lood Stove Safety' informa tion for vood burning
appliances and prel~minary inspection standards. I turtherstateH,that-the appli?nce
I Cim installing' meets smoke .emission standaJ~ds 'as set by the Oregon Department" of,
, Environmental Quap ty or the Federal Environmental Protection Agency and I agree to
provide the, testing approval number to the inspector at th~ time of inspection. I
also understand that if I am requesting a pt"climinary inspection, the vall covering
maybe required td, be removed.
J;:~~ u4S..f ~/) Ec. . L c..
SIgnature 'i~ ~r.. .
cccc=======================_==
1/. P.
. 4pttt l., I
,Date '
,Iqq~
"
========================================================
, '
, , ,
FOR OFFICE
USE
X
PRELIMINARY..
REQUIRED INSPECTION(S), VO?DST9VE/PELLET/INSERT
Date of Application:, 4/ IS/crt " ,
, . ' <1"}O/
Total Amount Collected:.:Dll.1. /100
Re~'eipt II: OI1tf3S
Job II:
9 ~o.L/(j c; ,
Issued l3y:
.
~. WI~
,." .
,.. ;1; ,_
'~Checked for Deliquencies:-1l~
. ' .
Checked for' HistoLi,cal S.tatu~:lJ fJh!._..-.