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HomeMy WebLinkAboutPermit Miscellaneous 1994-1-7 r/ 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 -=Bh.VI'lA *-rrw k.) -e. ~ J('~~1feS2 .J - 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: eq(Oo Owner: .:- Phone 1I: 74(P7Z-55 Zip: 77477 / 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- - ..J I Contractor: -= !P.r\ ('\() -r:e c..LtV\.II llle, i"f' \: bJ1I Address: l{ (0 t7 CdiLJ,J.Jv";",, (2J J U state surcharge. Phone 1I: City: F .A<c,.!l..V\.!l Q Contractors Registration 1I: ~c{7_~&? , State: 8f2- Zip: q7L{~/ 1-'1 -9/ 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. ~Q _~9-- Signature - FOR OFFICE USE //7 /rvr ?>a te I ~ 'V 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~ .~ Checked for Delinquencies: ............. Checked for Historical Status: v---