HomeMy WebLinkAboutPermit Miscellaneous 1992-1-22
VOOD STOVE/INSERT INSPECTION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
"
-
225 Fifth S,treet
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: 5/Jb, .S- HlJ2f7771';;>ti- ,
Assessors Map II: / ~ /) J_ I'l d m)
Owner: 0) 2 ~ - /d//~/if
1 ,
Address: ;: ~ "l j,- C / ') /,
Tax Lot II:
(.? 'L.. 9/-1
City:
j.LJ/7J
State:
/:k
Z; '1 7/)
Phone II: . 74 ? - ~ 7 cJ ~
Zip: q 74';1&
Value of Vood Stove~~ove/Insert:
(please circle approprlate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge +
~
tb/Jvrc//SY' ~<:..,
$10.00 Issuance.
Type of Inspection Requested: ~~/~/~~
--. .
~~,(~
Contractor:
Address:
Phone II:
City:'
State:
Zip:
Construction Contractors Registration II:
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 Vood 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 Ouality 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 prellminary inspection, the wall covering
may be required to be removed.
Sign;e-~~f ~^ M' '"
/ - ,;>'.,2 -9:::l.
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTO~~NSERT ~ PRELIMINARY
Date of Application: /'- 22 - 9 ? Job II: 9 2I'YJ <S /
Total Amount. Collected: "25, "lS-
Receipt II:
's ')'s-s
Issued By:
/#~
Checked for Delinquencies:
<-----
Checked for Historical Status: ~