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HomeMy WebLinkAboutPermit Mechanical 1992-12-28 (2) SPRINGFIELD VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION UG6 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Job Location: \\'\1B~=~G(\f'(\o-~ iU~\ ~rn ~~ Assessors Map D: V"l D;;\8.~W Tax Lot D: nrJ ;=<"(Y) Owner: ~ )1' l\ 0,\ f\ ~ n. ') \h ~r %~_) Address:-\~4-13~ Gn ffiQ -~edl Phone D: 'Vth -04R?; Ci ty: ",-1Q}~ di State: (CJ ~ Q!\fffi---1 Zip: qrwlR Value of ~OOj ~tove~pellet Stove/Insert:~~ (please-circle appropriate appliance) Preliminary.Inspection is $15.00 (prior to installation. of insert) Vood Stove/Pellet/Insert permtt~s $15.00 + $10.?0 Iss~ce + ~ state surcharge. Type of Inspection Requested: '\:1\ ~ ~ s\~ rc1.L(\l\ \\< 0 ~ Contractor: I.. \ULt.~D \ (\ f\J"\ 'J-.~D ~ .' Address: 41 n~ c'C')~\tS\(',~~ _ Phone 1I: '34-0 -<c.n~)l7 Ci ty: T -' '\0,0 f\Q J ~tate: (Uu ~ Zip: ~'WJ ( Construction con~actors Registration D: ~~ ~c:\ Expires: q. q ,q:\ -- - 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 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 required to be removed. \;;agr1O;V-== / /4.. ( ~ (q VJ... Da te - \ FOR OFFICE USE REQUIRED INSPECTIoN(S): VOODSTOV~~~INSERT ~ Date of Application: '\[:).:;p...." Job D: Total Amount Collected: d~'l~ Receipt D: .-, (j) \ Issued By: PRELIMINARY Q Q \'l~ ~ Checked for Delinquencies: Checked for Historical Status: