HomeMy WebLinkAboutPermit Mechanical 1991-11-19 (2)
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
Job Location: /2 ~ 7 rA-7.r?//.?~]JR.
Assessors Map #: /7V' S' 2...7 12- ""'.
Tax Lot #: 0 j rOt.?
Ovner: ~ cPu/~'J~ l
Address: 5'"':2-7c9 N/~ /'ME' Phone #:
City: /:74c::{aJ6 State: ~
0/7<20 ~
Value of Ilood Stove/pelle~ve/Ins;;;:V: r..4l_;.;.~
(please circle approp~l~~c ~ppliance) .
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Zip:
Q740S
Preliminary Inspection is $15.00 (prior to installation of insert)
Ilood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state surcharge + $10.00 Issuance.
City:
<322.
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Type of Inspection Requested:
Contractor: .C~l)
State:
C1)f ..
-z.~ 7~ .J
Phone #: 7~C. -~ 2- 2-1
Zip: 7'747~
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Expires:
Address:
Construction Contractors Registration #:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I vas provided vith the Ilood 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 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 vall covering
may;, required to be removed.
X A.t~u Q ::!//../A_~ - 1/-/9 -'1/
signatu~ (/ C/. / Date
FOR OFFICE USE
REQUIRED INSPECTION(S): 1l00DSTOVE/PELLET~ u.J~l) PRELIMINARY ~
Date of Application: // - Iq - 7' /
Total Amount Collected: 2 1'),7 S
Job #:
7'//2 74
Receipt #:
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Issued By:
r~V~
Checked for Delinquencies:
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Checked for Historical Status: 1__
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