HomeMy WebLinkAboutPermit Mechanical 1993-1-20
SPRINGFIELD
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: \4\d\- Q\)\\\() ~tJ
Assessors Map ti: VI02::hl ~'6 d
Owner~ \\'\\) m U , ~11 f\~9 .
Address-: \4lrA- Ol ~ tnf\ 0+,
City:~~rl \ State: (9~~\t""_J
Value of Voo~tove/pellet Stove/Insert: 1\ ~
(please circle appropriate appliance)
Tax Lot ti: OI~C()
Phone
ti: 14-,- f)~1~
Zip: Ql4, J
Preliminary Inspection is $15.00 (prior to installation. of insert)
Vood Stove/Pellet/Insert permi~ is \1~.~~ -: $10.00 ISS'Jf\~~ ,+ ~
Type of Inspection Requested\ JJ 'j\J) .Wl' fY\QSt lj; l\lVLl~
. Q
ContI'~:
------
state surcharge.
Address:
Phone ti:
City:
State:
Zip:
.~
Construction Contractors Registration ti:
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 t t if I am requesting a preliminary inspection, the wall covering
may be req ired be removed.
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/ignature
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Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
(-/Jn~q~
l~dJ
Date of Application:
Job ti:
PRELIMINARY Y
C1?/YJI d7
Total Amount Collected:
Receipt ti:
'7/)((/
Issued
By: riliJo..
Checked for Delinquencies:
y
Checked for Historical Status:
.
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