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:\
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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.
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Da te - \
FOR OFFICE USE
REQUIRED INSPECTIoN(S): VOODSTOV~~~INSERT ~
Date of Application: '\[:).:;p...." Job D:
Total Amount Collected: d~'l~
Receipt D:
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Issued By:
PRELIMINARY
Q Q \'l~
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Checked for Delinquencies:
Checked for Historical Status: