HomeMy WebLinkAboutPermit Mechanical 1995-5-8
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UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF, SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: l~t.o1.. AI\Jf)~A) L-MJ6
Assesso~. Map #: 11 {)1ll-1 tJ(J
Owner: Y~~T Ceo/( v' -
Address: '3 Co:2.. Auo~ LMJ(;
Ci ty: ~1l.'kJ(,,8..t3.~1\ State: ~.
Value of Uood Stov~~Stove~er~t '2:? ttl ~
~liminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: 9R.e ~ ,~^L
contractor'~1tA1'> ~""_ ~ ~
Address; 3. 0;;2. S t1hSVHli L ...':'c .
City:J:U~WE=' State: ~
Construction Contractors Registration #: C7G,~~~
Tax Lot #:
DUff1
I
Zip Code:
7f./Cc" '10;9 '3
a/tltl
Phone: #:
$.45 administrative
Phone #: Co~- ~ 7Z";
Zip Code: ql40~
Expires: 1-/Qb
,
By signing this permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
-and that I was provided wi th the Uood Stove Safety information for wood 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 wall covering
may be required to be removed.
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Signa~'Y W (JA / iJ. P. Dat'tI
~~~-===~=~==~===================================================
FOR OFFICE USE
REQUIRED INSPECTION(S), Y~~~O;~/~Y/INSERT
Date of Application: VjVb^1~
Lf{~
'l9.3'
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,; -
PRELIMINARY ~
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Job #:
Total Amount Collected:
Receipt #: -O-111d2J
Issued By:
IX
Checked for Deliquencies:
K
Checked for Historical