HomeMy WebLinkAboutPermit Mechanical 5-10-23
WOOD 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:
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Tax Lot #:
~ <:9 Co 0"0
Assessors Map #:
Owner: UJIW""" IL' ~ \J~.l~ , H-OM ^",
Address: S-g1 hoA-W\\tJ()t1
City: ~P~lyJ()FIl~ State: 0.
Value of Wood Stove/Pellet Stove/Insert: '-38". DD
Phone: #: ., 7...Co- gY3 I
Zip Code: qI4))
Preliminary Inspection is ~l~O (prior to installation of insert)
Wood Stove(pellet/Inserr-Permi~is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = 526.20. total n~//~..:-' .
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Type of Inspection Requested: I-''^.)Al.. ~~.n ~L~~~/St=- ;:::.#/
Con tractor: tZ Al.-~ H (J':::I-~ nO OIl':::/} (';.A.')~~I00
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Address: ~7S"" ,/J I L~,J C:, . Phone
City:E""''-EtJ6 State: ~
# : G:> i 1 - <:) q C.", 5?
Zip Code: Q7tJO L
Expires: '? [q\
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 Wood 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 be required to be removed.
#: 9~~!
Construction Contractors Registration
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1 gna r e ~ .. ~ ~ I Da t e
==-=== ==--=~~-~=~~~==================================================
FOR OFFICE USE
REQUIRED INSPECTION(S): WOODSTOV~IN~E~~ ~.
/O/2~/5',)
I I .
2..tP ' '2--0
PRELIMINARY
Date of Application:
Job #:
9~/~7[)
Total Amount Collected:
Receipt
#: /11~
Issued By:
d~
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Checked for Deliquencies:
1/
Checked for Historical Status: