HomeMy WebLinkAboutPermit Mechanical 1993-1-22
SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
I y {" L.j Q \,{ lIA tJ I+- Sf-
Assessors Map #: 17D 320":::>2....
M e rr-~ I \ B u. v j..e.....-
Address: \ t.\ \0 L\ G.lv() \II. o.J + 25f-
City: SOft oi State: 012-
I '
Value of \/ood Stove/~llet Sto;~sert~ Jf~1 on ,00
(please circle appropriate appllance)
Job Location:
Tax Lot II: 01 2-d:)
Ovner:
Phone II:
I Lj7-DR-7~
Zip: '1 7L/ 77
PreliminarY.Inspection is $15.00 (prior to installation, of insert)
\/ood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + ~state surcharge.
,1~
Type of Inspection Requested:'/V1S-r-o. (( cchllVi
Contractor: !i-8(' ~ f.h., ..'^ \i\.LJ SP('\I:( P
Address: rp 0 ~OJC 2-35c)Co
Phone #:
H-u f+)
~
q ~7-/~==>'q'J
Zip: q7L/n7
;:;-1'5 - q:~
(-r."rl
Ci ty: ~ 11~ P.1r..J) _
Construction Contractors
State:
D12-.
Registration II: 77-; &0 to
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 vas provided vith the \/ood Stove Safety information for vood 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 ap al number to the inspector at the time of inspection. I
also understand that : f am requesting a preliminary inspection, the vall covering
may e requir moved.
/112/73
Date
FOR OFFICE USE
REQUIRED INSPECTION(S):
\/OODSTOV~iT/INS;o V PRELIMINARY
-'2--2--CJ?;; ---JOb II: Q30D\..p7
ZC:). 7~
Date of Application:
Total Amount Collected:
Receipt II:
I~I sr
Issued By:
(Gvv.
'"
Checked for Delinquencies:
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Checked for Historical Status:
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