HomeMy WebLinkAboutPermit Mechanical 1992-1-15
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Assessors Map II: f 70 '-:>2-6 3 ~
f I (JIA vi uJ /Jrrf-oV)
Address: I Y () 5 0 \!'j VI CLcT g-
City:_ s:rftd State: Df-- Zip:
~2p{)ZJ ,a:>
Job Location:
Tax Lot II:
() '/.-.062)
Owner:
Phone
II: '7U -97i?~
q74i7
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state surcha~~ + ~.OO
Type of Inspection Requested: _?V -e { IVvI)7A. {j rtd--" V?~
Contractor: tho r:va-fJ-f-J;;,--'bJ~Q. C€.ti!J-~
Address: I~ F5 1}jPiJ-- 0/l1 -kl/ R.--
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City: VA1~~ State: /)12-
Construction Contractors Registration II: Lj~f7~
, -
Issuance.
Phone
II: Lf'?8-~
Zip: 97t.f--O"2--
(if; <" ';fft z--
Expires:
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 was provided with the Vood 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.
~uJt;"r,
Signa ture . V
it:-<<.. / C / P t? /.--
Iia te
FOR OFFICE USE
REQUIRED INSPECTION(S):
VOODSTOVE~INSERT
V PRELIMINARY
Job II: . qU!D3-!
~
Total Amount. Collected:
1-(;;')-12-
L-f n.76
Date of Application:
Receipt II:
':~rr2-q
Issued By:
~
Checked for Delinquencies:
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Checked for Historical Status:
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