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HomeMy WebLinkAboutPermit Mechanical 1993-5-5 YOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 l'l.f A /-I,QA) ,AtLE J 7 tJ3 2. ~ 'S".3 ',L I ~e:( T/ S Address: 'j 74.AU--t"50 Av~ . l I City: ~~/tV~?/e(,,-) Value of ~d~/pellet Stove~~ (pleas<< circle appropriate appliance) Job Location: Assessors Map #: Tax'Lot #: ~ .C;I'.JU Owner: ])ON Phone #: 7?7-IZ/.s: Zip: 9'7~ 77 State: ~ / /~{!}CJ Preliminary Inspection is $15.00 (prior to installation of insert) " Yood Stove/Pellet/Insert Permit is $15.00 + $10;00 Issuance + $.75 state surcharge. Type of Inspection Requested: jNsOer Contractor: p~...-;-~r /r//f"e.TAjO<'.,S. Address: -?'"/J Jc'/~ ~.oJ:? . '. ' I ' Construction Contractors Registration #: ,7n9/alJ Phone #: Z~S-~~'A- Zip: <7?~~ / Expires: / -3 - 5'<1- , Ci ty: We:::. State: ~ 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 Yood Stove Safety information for wood burning applianc~s 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 th~t' '~m '4 sting a preliminaryinspectidn, the wall covering ~_ r r,e eqqUUir~,t , . ...._CJ . , , .~ /'I _ )J 5/S/9j: /- Sighafure C7 ~y Date /' I FORbFFICE USE REQUIRED INSPECTION(S): YOODSTOVE/PELLE~SE~ 5-~-ey3 2f;;,7J' ~ PRELIMINARY Date of 'Application: Job #: 9<o.)~ Total Amount Collected: Receipt #: ~ :a,7~' Checked for Delinquencies: Issued By: ~~ ---r: Checked for Historital Status: ~