HomeMy WebLinkAboutPermit Mechanical 1991-12-5
SPRINGFIELD
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: .~?./ eJACJ.. ~
Assessors Map II: \7 v?) 7...hJz...~
C-,\A. evil eS b4- l? 11 1/\ l+ttJ~
Address: ~2-- f1\Q~ CI\7f
Ci ty: ~tJ State: (~-,2---
Value of Vood Stove/Pellet Stove/Insertpt~~ ,~
(please circle appropriate appliance) .
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Tax Lot
II: 6tJ70 CYJ
Owner:
Phone
II: 7Lf:7-3769
Zip: _tt1 cfffI
preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state surcharge +
Type of Inspection ReqUested:' rv~\\A.-~
Contractor: Gl5lJ& J4... CL-O ~ JA)~
IVltLm
$10.00 Issuance.
Construction Contractors Registration II:
7/",4;;'"
Phone II: 7lf.fo-foz2J
ziP:3/i7~
Expires: ~ - 2fo -92--
City:
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State:/)y2.-
Address:
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 vas provided vith the Vood Stove Safety information for vood 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 vall covering
may be required to be removed.
~m.7M.J~
Signature
/2 -5 - q I
Date
FOR OFFICE USE
Date of Application:
VOODSTOV~i:~SERT)
(2-- -J:) _ell
ZF\ -/'7
~ PRELIMINARY
1 t/ 2--q~
REQUIRED INSPECTION(S):
Job 1I:
Total Amount. Collected:
Receipt II:
~2fJrJ(' )
Issued By:
{L~
Checked for Delinquencies: ~.
Checked for Historical Status: ,...........