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HomeMy WebLinkAboutBuilding Miscellaneous 2002-9-30 225 nrrH STREET. SPRINGfI[LD, OR 97477 . PH:(54 ])726-3753 . FA.X: (54 ])726~3689 E11 City Job Number (;2'- 00</5(0 -O( ~ .. ,,--,4 Job Locatior ~ ~ Assessors Map ~ ..~~ '. ~ Owner ~ Address ~ ~i ~ City ~: Q .>~ ~ ~ ~' ~ I Contractor IlIformation ~ Contract"r ~fAI/A'Z- Addresf ~j ~ ~ a ~j ~ ~ a ~ ~ ~ ~ . . , CITY OF SPRINGFIELD, OREGON '(,I\"",~ " " '.- ,i\l-j.\ ...,,' L . '.' '.' 1 D(.\~I-l C;;':T I/I :"\'l,'r Ill.. _. 4 .J. j A;ii J\::LiJ:: .; J.l. L, '.:J L~1\ ~', ~r:S\'j.:I~ \ :.~ / 3ft' VV, (j v I A/14 II 1/0"3273 Z- Tax Lot c>O/6] j? /7 IV 1""7 ( 10 5", l/ ,. < t... (3/(/ {/J- Q (/ uVP! // <;e f'c) (; Value of Wood Stove/Pellet StovelInsert: 7 50cJ, Phone tot -6~~5 State -at? Zip C17V77 0::> (please circle appropriate appliance) Preliminary Inspection is $45.00 (prior to insert) Wood StovelPelletlInsert Permit is $61.75 (includes Permit, Issuance Fee, State Surcbarge & Admin Fee.) Pbo'p .~ Cit~, ~H'.l.t"" 10"""1 r.,s, '; "-'\\" .' \ Zi ;\\\\.-' ......,\\J\~:..O\\' ,r ~.' . . '" . ',.,. '::.)V .__" ,.- '-..' "Lo ..r).... \ ,,\ P"'" ',' 'l -, F ,'~' ("' oJ) xplres L ., - ,..~' ,'"'..J ~ \' . ,'~ ( . n~.' C .-,\l,....."-..\os. ,.t-\\'~" ,~,,'.:.\v.\_o~ ^ Construction Contractors Registration # ,\~..' "".-.- l';/~\.~'''' \\\',. ,::-r..,u_'I,)'~\. i-\,.... . \~, r"" . ,,"\~ "'......'\.... ,,:\\\G By signing this permit/application, I agree to call for an insp'ection(s).as'required,F26c316Q). ,I'state that all information on this application /permit is correct and that i"~~~:pr~Yjde-ci:~,ith')lh.\,W86dJSto\~S'afety information for wood burning appliances and preliminary iri~pe~iib~.:itari1i'alds'~s ~~t-.By,!hi?Oregon Department of Environmental Quality or the Federal Environmental Protection'Ageric~' and;l)agree"to provide the testing approval number to the inspector at the...fime of inspection. I ai~~lud'deiStaila 'ihatV I am requesting a preliminary inspection, tbe wall covering may be required to be r~\Iit~ed ~ >," Signatuf'> t _--YUL ~ Date of Application D e'i. ,~O .... c>2.. \~~ \~ ~ ~ \':1 ~\)\ . ~ ~i-'? "c,p..\ol)\ .r1) ForI\.Qfff~~~~~\\ ';)l\~i~ \\\\:,~~~~'\) {u'- ,-.. ~ '1t-~ ., '~\u l>-" r",.v 7 -:1 0 -6 Z \~~~~C)~\1.;~; C)~ \~ : l'-~C)~~\:.~D~'l ?\;.T\(:. Ji'l\e\'R~d for Historical Statue 1'" Checked for Delinquencies L-- r- Shared Drive(T:)lBuilding FormslWood Stove Pennitl~2.doc