HomeMy WebLinkAboutPermit Miscellaneous 1999-3-22
. .
-.
.
SPRINGFIELD
te hI> egon Utility
WOOD STOVE/INSERT INSPECTION APPLICATION Notifioation enter. Those rules are set forth
CITY OF SPRINGFIELD in OAR 952-001-001 0 through OAR 952-001-
COMMUNITY SERVICES DIVISION - BUILDING SAFET'()090. You may obtain copies of the rules by
calling the center. (Note: the telephone
number for the Oreg<lJJflilll!jtm6l1jq,)9tion
CINlWOOlTI6l>lJh~:2~~769
225 Fifth Street
Springfield, Oregon 97477
Job Location:
2hg/
G --+-n.S 0 tJ'
!-Y
w
o
t::
~.
~
Assessors Map #: /, II 1, '"\ t_ II
J}6/1/A lei 7 A-c.-k~<> ~
Address: 2(, F ( CA-K~
~ 6 City: 5/)!IA/y, /A !rei d State:
::~o: I ~I -Co,/.
W f- N.alue of Wood Stov let Stov sert: /.j u v
j!:~fil
!!:: ffi 4!l'eliminary Inspection is $15.00 (prior to installation of insert)
~ ~ ~ood StovelPelletlInsert Permit is $15.00 + $ .75 state surcharge + $.45 AdministrativeGFee 1-$.JO:00
ii: X ::tSsuance.
xf- '" Iirrtf
W D a. "...,.-. _ j j __ '# {rJ1'f'"
::l W TvnA ofInspectlOn Requested: ;;"'V/bN ~i _ J .~: :.? ' '. . ":7 ~ ,_ _--:-
< D .Ie v __
:r~ 0: _
~ =:' Co'Kiractor: rlJ.i.:!~b")'-'~'ll.IjA
~f; >- - C .
:; ~. '.~ ~I . rj. I
ffi f: . A~ess: . n' .._>1 ~ ~'\'tf):1"""
C ' Cii: ')f~JV7r;EI/ State:
<(
Construction Contractors Registration#:
Tax Lot#:
10 /0 l/
Owner:
Phone#:
7 'i- If - <:F 17' /,
Zip: 17 tf7 7
OIL
(please circle appropriate appliance)
Jro;) '.
Phone#:
7LfY- 'tIC) C-
ti1-'I77
()^
Zip:
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 Federal Environmental Protection Agency and I agree to provide the testing
approvall\umber to the inspector at the time of inspection. I also understand that, if I am requesting a
PrL~2ec;'Ci1Je~;;r~K~/~_ 2 q _ 9q
Signature G/. . Date
FOR OFFICE USE
REQUIRED INSPECTlON(S): WOODSTOVElPELLETIINSERT
1/2-1/17
Total Amount Collected: J-/, 2.-<1
Date of Application:
.3-31-'ii
Job #:
PRELIMINARY
!/Y()'Iv8 Cfl61o~
Issued By: d ~
Receipt #: () =3 ." "3 2..6
Checked for Delinquencies:
Checked for Historical Status: