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HomeMy WebLinkAboutPermit Mechanical 1999-10-13 . . WOOD STOVElINSERT INSPECTION APPLICATION CITY OF SPRINGFIELD COMMUNITY SERVICES DIVISION - BUILDING SAFETY 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726.3769 Job Location: t:, I f ~ITS. ~J /7C77?'2 S/ A~'E~~f~~"J Address: t, I ~ $~1>'\r!' (;i-bJ.i . City:~t:"II="LI\ Assessors Map #: Owner: ~ Q. .Tax Lot#: 64/:< c:;>t:::) State: !)fJ Phone#: 7J//-::22.s;7 Zip: ~I7J?7 . Value o~oocf StoveJPellet StovelInsert: I q 00. 00 (please circle appropriate appliance) Preliminary Inspection is $15.00 (prior to installation of insert) Wood StovelPelletlInsert Penn it is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00 Issuance. Type of Inspection Requested: ~~ M- contractor:~ (2,JJc:::cr;-b J :th_. Address: AIJ[,~ IJ J . J j+g City:_ ~f!?JQ State: IJR Phone#:.:r:tls:- 7.1L>~ ziP:9~~:J.....- Construction Contractors Registration#: ~(!JS , lJ ~ II/L Expires: By signing this pennit/application, I agree to call for an inspection(s) as required (726-3769). I state that all infonnation on this application/pennit is correct and that I was provided with the Wood Stove Safety infonnation 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 ~rel' inary inspection, the wa vering may be required to be ~moved. d\P" >,O~ \ /0 v/1-19 Signa Date FOR OFFICE USE REQUIRED INSPECTION(SywOc)'DsiOViWELLETflNSERT PRELIMINARY Date of Application: /..tJ -~ ~'?'7 Job #: q9/L/~ Total Amount Collected:.26. ? ~ Receipt #:. -;;ij. :..;-~:? Issued B~....--~ . -7"" ... Checked for Delinquencies: Checked for Historical Status;