HomeMy WebLinkAboutPermit Mechanical 1999-10-13
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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
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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~....--~
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Checked for Delinquencies: Checked for Historical Status;