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: