HomeMy WebLinkAboutPermit Miscellaneous 1994-9-8
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD 1~.~ D n
BUILDING SAFETY DIVISION l~ JU
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 50!:'1: r:<.s'1.fil/a.. Or.
Assessors Map ~': /g-c>< -cs-r-c::>6 Tax Lot~: <=;2-:;'4>8'
Owner: tA1a.<rk. ,4. f'oslc.- ~ CQ..Jor(~"'- 15u.ya..",-,f
Address: ~D"2..<6 +:<,vsyfl....:G.. -oV'. Phone:~: 7U ,- G 77-'1
City: ~'P~l& _ State: ()Vq Zip Code: CJ]L(7f>
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X Value 0000d Sto~/Pellet Stove(Insert1) t{;-O. f) cO
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Reqllested: ~~~ -~~~
Contractor:P.~/7?4A.P-:'~~ 0A~ ~~~c!"'"7:)
Address: C/2~~ ~-~.- c:Azu~~/# Phone~: ~//"?7
Ci ty: ~ - :r 'i""'~.A-....JE:.... State: ~ ~ Zip Code: c::l7':':::;:~
Construction Contractors Registration ~:2~'2~O Expires:-/&>-'":Y-~Y
By signing this permit/application, I agree to call for inspection(s) as reqllired
(726-3769), I state that all the information on this permit/application is correct
and 1:hat I was provided with the Yood Stove Safety information for wood bllrning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards. as set by the Oregon Department of
Environmental QlIality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection, I
also lInderstand that if I am reqllesting a preliminary inspection, the wall covering
may be required to be removed.
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Signa tllre
s~P, CO J ft 'I
bate
=======================================================================================
FOR OFFICE USE
REQUIRED INSPECTION(S): ('WOODSTOV~PELLE~
~-$i'-9'Y
Total Amount Collected: ~~. ~
PRELIMINARY
..
Date of Application:
Job~: ~ /3'97"
Receipt ~:~~~~
Checked for Deliquencies:
~
Checked
Issued By: d~
for Histor:ca~~tus: ~