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HomeMy WebLinkAboutPermit Miscellaneous 1994-10-7 SPRINGFIELD WOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth S.treet Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location: :;Z'-I;( I~ f)u;w. ~;nJPd,(),f CJ7tf17 Assessors Map II: /7r"):~ ?. 2- ~ ( Owner: ;/j~!t /u-A~1tid . Address: dgcj2 1---Ua.ra..- ~ City: .A'./J)I//Ylr/hld State: ()K 4- P Value of Wood Stove/Pellet Stove/~ ~t70'{)O (please circle appropriate appliance) Preliminary Inspection is $15.00 (prior to installation of insert) Wood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state surcharge + $10.00 Issuance. Tax Lot II: nc:, 7~1)_ Phone II: 7'/f;-279/ Zip: 97<)77 Type of Inspection Requested: Contractor: 1113(1. (I/;/~1AUt/. vff)}..""./fl~J {f ;P/PEk~r'-Ohe-U ! Address: P /J. fJlnL ~1C;Oc, City: L n ~/Y1P > Construction Contractors Registration II: '1if?of., Phone II: (!Tl-?q35 Zip: 91<10-:1..- 5/9S State: OJ? Expires': 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 was provided with 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 req~y,~d~ r~~ 77 (j/}UI f ~ 7J1,'j, Signature 0 /0- 7-1'1 Date FOR OFFICE USE REQUIRED INSPECTION(S): WOODSTOVE/PELLET/INSERT Date of Application: /0 / ~/?"-i- Job II: Total Amount Collected: /S ,c; 0 PRELIMINARY ~ ,Alx W=cJ.Yi'VJ/e q~/S--?? Receipt II: /-1- ''/7 7' Issued By: K~~_ Checked for Delinquencies: Checked for Historical Status: