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:
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