HomeMy WebLinkAboutPermit Mechanical 1992-1-28
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: .2di4 Fle:fft iJul?- SfPitvc} ~JJ
Assessors Hap II: I!JD,"" ? S 12. Tax Lot II: 1?~-7tJtJ
Ovner: I" ),4(',C'_ i lt1e've.s-e WA:::..~;,,,
Address: _~)1'p
Phone II: 747 -~ II s:-
City: State:
Value of~ood StoveYPellet Stove/Insert: ~b(J~
(please circle appropriate appliance)
Zip:
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge +
Type of Inspection Requested: l/.J;:Jod S~i/e J;,x:jdj.J.o...~
Contractor: 1 A1Ve~, UJALi{1r/i - 4J ~/J!'.--c<:..
Address: ""$5"a9 ./Jf'~j)J} "/;'/h Phone
City: ;;./.~ State:~
$10.00 Issuance.
Construction Contractors Registration II:
II: 3'12-75)/
Zip: fj11~/J /
Expires: 9hr7/99..
~ /-
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 with the Yood 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 r the Federal Environmental Protection Agency and I agree to
provide the testing proval number to the inspector at the time of inspection. I
al,SO understand t if I am requesting a prelIminary inspect/aion, the wall covering
ma~ b! :equired be removed.
II~...--? ,____ 1 z 8~"2-
Signature I Date
FOR' OFFICE USE
<44/%
REQUIRED INSPECTION(S): ~ODST~PELLET/INSERT
Date of Application: ~ I /2~h2 Job II:
~ 1- I -
Total AmountCollected: 2. S, "J
V PRELIMINARY
q 2 ()v7 z..
Receipt II:
'2,&94
Issued By:
#~
Checked for Delinquencies:
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Checked for Historical Status: