HomeMy WebLinkAboutPermit Miscellaneous 1994-1-7
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: Ul.Jl <;(1f1~ 6 k~
Assessors Hap 1I: 170'37-713
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Address: Lf l( I \7' ~ f, f../} ~
c;;o(2rI State: (ffL-
Value of Vood Stove~Stove/Insert: ~ (lJ/~l!5O g]).
(please ci rc1e'-aPPl'opt"ia te appliance)
Tax Lot 1I:
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Owner:
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Phone
1I: 74(P7Z-55
Zip: 77477
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City:
Preliminary.Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75
Type of Inspection Requested: -WZ{,..~loV\ f).e,f,trl-
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Contractor: -= !P.r\ ('\() -r:e c..LtV\.II llle, i"f' \: bJ1I
Address: l{ (0 t7 CdiLJ,J.Jv";",, (2J J
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state surcharge.
Phone 1I:
City:
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Contractors Registration 1I: ~c{7_~&?
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State:
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Zip:
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Construction
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 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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Signature -
FOR OFFICE USE
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REQUIRED INSPECTION(S): VOODSTOVE/PELLET/]NSERT PRELIHINft~Y
Date of Application: i -7 -~~--- Job #: Qlfrn7.-/"'::1.,
Total Amount Collected: 2..6.1t) /\
Receipt #: \\~ Issued By: GG~
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Checked for Delinquencies: ............. Checked for Historical Status: v---