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HomeMy WebLinkAboutPermit Mechanical 1994-8-18 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: C:,~ I I2~AJtE/l... ~T: -lA. 00 Assessors Map II: \ l () :<) :; :::> I t./ O"ner:ill",!~1) <L tt1A)tJ~I: lEG Address:~1 f2A/..JueL S', I Ci ty: <:;::'p~IIl)~ F,afl State: Value of Vood Stov~llet St~~Insert: (please circle approprIate appliance) Tax Lot II: O(Yi 0 (., f'), Phone II: 72.(" - 70/1 Zip: q7t/17 00 7_7,cj7 _ Preliminary ,Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permi t is $15.00 + $10,00 Issuance + $.75 s ta te surcharge. 1" ~ Mlki\.! J\, "IS> Type of Inspection Contraetor: ~.PiJ Requested: - -1-'.'41 Address: S'7s.-W/LSoAJ lJ.)I=.~//:II. (OAls''HJlkT'IOt\..J I - S;- Ci ty: F:'0C, f'''-..HS- State: o Phone 1I:...Lor< ~Oqc;.V Zip: Cf7'-ID2 Expires: '1....,lqy Construction Contractors Registration #: q~-s-~ I 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 "as provided "ith the Vood Stove Safety information for "ood 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~'" ~ uesting a preliminary inspection, the "all covering may be required to be rem ved. 1--;Ij6Il,btN,,~.AL71e;.J;K~ 11<<.AllU1-,llP. Au~ It l(jc;ti SIgnature f ~ Date 1 FOR OFFICE USE REQUIRED INSPECTION(S): VOODSTOV~INSERT ~ PRELIMINARY Date of Application: f-lY' -'fLI Job #: qLr I L)p7 Total Amount Collected: 'f7.-e,-?,.O Receipt #: ILf?41 Issued By: Ii~o t.- - Checked for Delinquencies: ..-/ Checked for Historical Status: ,/,