HomeMy WebLinkAboutPermit Miscellaneous 1998-11-19
.
.
~i;);/I~(cj~I=/IJJFJ;l:iiif) ,
VOOD STOVE/INSERT INSPECTION ,APPLICATION '
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth' Street
Springfield, Oregon 97~ 77
SPAINCFI€LO
Office:, '726'-3759
INSPECTION LINE;- ~26-3769
-
preliminary Inspection is $15.00_ (,pripr to
\load .Stove/Pellet/Insert Perini t is $15.00 +
fee + SlO.OOlssuance 'c $26.20 total '
Job Location: 97 f' G(/) lUll f r-:5-r- .s{hJ.J(rf7~j<i_;
Assessors H-;p ~: /?-4=:J':;>~~ </2 'Ta;: Lol ~: ~~G:> ,'./
ovner:~t....y I~;/I~€ /It:J-t<,.,.:.., '.'
Address:.9')); rfJ~J.~/..tA/7 5 r-" Phone: ~: ",
City:5o'hf../~(cf()t-- State:..QV-Hcf,JW Zip Code: 971'77 -'f
I /I,I} ~tlUT".,
Value of \load S(ove/PelletStove/Insert: ~~~ ~ 6.? a.~\t''!~ 'S~O\' '
. {:.:I-'?~T' ~\\ ~ '
install~t~iC~'f .inS'~lit" '\':\'\\S'?~~.c\'\~O\'\. "
$.75 s'tate ''f~,t\~Hl~~~'s', ~5,)Qldministra ti ve
\~\S O\'\.\t~\) ~ \'0 ~'O~
t>-\.Ii~,,~~~c.~I,). ~1"y\\q0.
.'
Type of Inspection Requested:
Coo <no '0" A [') (T <5 T" {}u S fL.. {// "- 'R;d' "(-r!i<"i 1;f::ff :Iff:.
Address: P()(6(\'/... /D~ ()Ii'x.rf((r Phone~: 9 77- ~ .
City: n ~ ic'tlt.r State: 0 r
Zip <;ode : '
Constructioo Contractors 'Reg~stration 0:
Expires:
By signing ,this permit'tapplication, I agree' to' call for inspection(s) as required
(726-37.69). I state that all the information on this permit/application is correct
and .that I vas' provided vi th the \lood Stove Safety' information for vood burning
appliances arid prel~minary inspection standards. I ~urther..s tate.,. tha t- the appliance
I am installing' meets smoke .emission standard:; as set by the Oregon Department. of,
'Environmental' Quali ty or the"federal Environn.ental 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 vall covering
~If(:'d " b, "'0"'
Slgnature-C-
-
""----
. / (- 11-91?"
,Date
, .
cccccc~cccccc~ccccc==Cricc=~Cri=ccc======F~~=~~~~~~c~~~ccC=7===~~~~=~~~Z;~~==~~
REQUIRED INSPECTION(S) :<'"'t'OOI.J~TOVE)PELLETcrN~!~l\T)Y t:;:~INlUl.Y ~1/~ ~~
o. ._
Date of Application://~/l'_"9S2. Job II: - <9.J:?//,V.o
Total Amount Collected:
-?L2~
_ l~
'''checked, for Deliquencies:
Checked
Issued fly: ./?f:::::::' , .
~ ~~ }
for'Histo~ic~ Status:
Re~'e i p t II: .t?~2 .I~,,">
- -