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HomeMy WebLinkAboutPermit Mechanical 1993-8-25 ...~~ . '...,I!,,:....I'-..~.,...',:.f\r'1l"..;o.lI.,-_....,.,..',~,::'~'i,..~'(i~.:;...:.. ,.~~~..~~ , , . , , YOOD STOVE/INSERT INSP~CTIONAPPLICAT~ON CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street . Springfield, Oregon 97477 . ,Office: ' 726-3759 INSPECTION LINE: 726-3769 Job Location: --t<~ S S- *"~__ Assessors Map #: /'?c:J2 .3' ~ ~r ~ Owner: /.n~7/A) ~~ , ' Address: -P31ff~ _M?&e Ci ty: S:;P~) State:,,/jj,e' ;. " ~ ..... Tax Lot #: 0CJ1 Value of Vood Stove/Pellet Stove/Insert: (please circle appropriate appliance) Phone #:, '7 2.. ~ - 8<106.. ,zip: ~ 7,~7.e Preliminary-Irispection is $15.00 (prior to installation of ins~rt) Vood Stove/Pellet/Insert Permit is $15.00 + $10~00 Issuance ~ $.75 state surcharge. Type of Inspection Requested: ~~~~~ , f Contractor: Address: Phone #: City: State: Zip: Construction Contractors Registration #: Expires: By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was provided with the Vood Stove Safety information ,for wood burning appliances and preliminary inspection standards. I furth~t siate that the appliance I am installing meets smoke emission standards as set by the Oregon Department of Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing approval number to the inspector at the time of inspection. I also understand that if I am requesting a preliminary inspectici'n,the wall covering WJM;;:emoved.. 4v~ .:<J;/,",?J Y Signa ture _: ',' " , Da t'€ . FOR OFFICE USE' REQUIRED INSPE'CTION(S)~np$T~~~p. ",,,,'~i> Date of Appli~atibh: ' Job #: , PRELIMINARY" ~ q ~ Ii 4. / / '-"'1'1 Total 'AmountCollec ted:' / S. 0-0 Receipt #: !~P(_/J' Issued By: ~~ Checked for Delinquencies: ~ Checked for Historical Status: