HomeMy WebLinkAboutPermit Mechanical 1993-4-27
I
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD '
BUILDING SAFETY DIVISION
J6P
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
/7#
ALLeN'
A tf e
Assessors Map #:
Owner:
/)ON
I 7 c:s .~ Z3 .3 3
L. BE r 7' ; 5
Tax Lot #: t:J 35"0 (S
Address: / 7 q A L. t..e)tJ
Ci ty: S PIl/N6 1='/ eLO
AUe..
State: ol2t::..
Phone #: 7 t.j 7 - I 7 / J.....
Zip: 97977
Value of Wood Stove/Pellet Stove/Insert: /~()~. o~
(please circle appropriate appliance)
Preliminary Inspection is'$15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00+ $10.00 Issuance ~ $.75 state surcharge.
Type of Inspection Requested: PJtBkh-?/A ,~V
, ~f
Contractor: ~) t.t...:nn:JJ'I'/OPh'
Address:
Phone #:
City:
State:
Zip:
~ Construction Contractors Registration #:
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 Wood Stove Safety information for wood burning
appli~ncesandpreliminary 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 i~l1J~" a preliminary inspection, the wall covering
reqUire~ ,be ( ot~ ... . t:j _ z. 7 ~ 9-3
n'a.t.d'fe " ~.., . - Date-
. FOR OFFICE USE
REQUIRED INSPECTION(S):CJfOODSTOV~PELL~
Date of Application: W'2'? /9 "? Job #:
'{ / --
Total Amount Collected: }c::; .t;0
PRELIMINARY ~
q'?rJ '5'6 rJ
, - -
Rec,eipt #: ~2.~'.S Issued By: //(:~
Checked for Delinquencies: v--- : Checked for Historical Status: <....