HomeMy WebLinkAboutPermit Mechanical 1993-8-9
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726~3759
I~SPECTION LINE: 726-3769
Job Location:
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\ f)(53:'~ 11 ~\
~1/)~1fdaZ.,D;f" , :\
,0 " /f\AA.~ 1
. Tax Lot, #: ur...rrl~
Assessors Map #:
owneilC{.f)o/lJ.,j_~:, 08 ;~fl)
A9dress: /~3>}' .I~./J~L
City: . x)M/;rd .... .'. State: (),e
Value o,f,Wood S tove/~elle t ' S to~Inser t : /7'.Jj.tj. 00
(please circle appropriate appliance)
Phone #:
Zip:
~1t/77
Preliminar~ Inspection is $15.00 (prior to installatibn of inse~t) ,
Wood StovelPelle,t/.~nsert P.~rmit>is $15.00 + $ .75 state surcharge +
Type of Inspection Requested: 'tJ.I/~J (\ [h/J/1%J7/ ~?U
Contract,or: ,It 13 e f!.)//)~/Yl..u.1 V#.AA~.IL
." ()
Address: to. /1011 ::J.:?_c;-O~
City: .l:J4L./I.U..J
~
Construction Contractors Registration #: ~?d(O~
$10.00 Issuance.
Phone
#: !J'3'7-39 305-
Zip: 9'7.y{)~
9~
State:
OA'
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 Fed~ral 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 required to be removed.
/}O/Jd~AL m/~h
Signature t
"y: 9-93
Date
FOR' OFFICE USE
~}'''\ "- /l
REQUIRED INSPECTION(S): WOOD STOVE ELLETA:NSERT ,7'-/ ,PRELIM:NARY
Date of Applicatio", n.9. Job.: q3 \\1'\ ;::),
Total Amount Collected: . cQS .1~ r . n . . )
Receipt.: q~Co Issued By: 'r1\\j:J,Q. ./
Checked for Delinquencies: Checked for Historical Status: