HomeMy WebLinkAboutPermit Miscellaneous 1997-9-29
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SP,RINGFtELO
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY Of SPRINGfEILD
BUILDING SAfETY DIVISION
225 fifth Sneet
S~ringfield, O~egon 97677
Office:
INSPECTION LINE:
726-3759
72"6-37691
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Job Location: 1c.j..tL.-'.....~i
A~sessor5 ,:ap g: I'lD 3 2.. 7
Ovner: P",.,.t'lIC. '" I.l'Lfi;l4Y104U 14
Address: 14Yl ~ln..04 .
City: SJ)."-"U(''='~ State:~
- . 0
Value of Vood Stove(pellet Stove/In~ 2. 'In <L:-
Preliriiinat.y Inspection is S15.00 (pLior to installation of insert)
'Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge. +
fee + $10.00 issuance = $26.20 t~l
Type of Insp~ion' ReqUested; m. 'lL. 1-'.r>4C ,
Contractor: f:rlc 1&>1-/ U )"'ew!2.&<./j.;:I( (r1i11"-'He..Uc..:T',CjJ,.)
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Address: :'\)C uj,LUl.u \/ .
City: ~,t.HtJ~ State: ()"
P--A-M V/ ~)
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~ 7-
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Tax Lot ~;
00/6 X
Phone: g: 71./<0 - S-5"n"
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Zip Code:'
q')~
$.65 administrative
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t:,~? - (")'(./"7.
Zip Code: ,.Q71/o ?
Consnuction Contractors 'Registration' ff:~Q5:l\'L Expires: 17(q'l
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By signing.this, pet'mi t/application, I' agree to call for inspection(s) as' required
(726-3769). I s ta te tha t all the information 'on this permiJ.w'plica rion is COHec t
and .tha t I vas provided vi th the Vood Stove Safety i~1lMi.~\<,n for vood burning
appliances and preliminary inspection standards. I ,~~iI~i\h'~ ,l&~e tha t_ the appliance
I am ins tall ing mee ts smoke emission ~ij.ndat'd:>, ~!/-'il'!fe b~W\ tl\'t\ Oregon Departmen t o-f
Envi ronmen tal Quali ty or, the Federi'A't~~rR''O~~~~ ,'J \~'te~tt&1r Agency and I agree to
provide the testing approval numb~t<t.~~ 11 oJ..b.~ the time of inspection. I
also understand that if I am reque,\~<Jag ~\~ i~\li);h~' inspection, the vall covering
may be requi red to be removed. ~~a C~Qa. r::J\)'
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Phone ~:
REQUIRED INSPECTION(S):
VOODSTOV~LET/INSEWf)
00~:
b.h, .2.0
PRELIMINARY,
. C?'7/'I72...--
'Job ff: / 'j'- ./
Issued By: . _~~
Date of Application:
Tolal Amou'lll Collected:
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Receipt
II: 2?S":?r
"Checked for Deliquencies:
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Checked for 'Histo'rical Status:
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