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HomeMy WebLinkAboutPermit Mechanical 1997-8-19 . . SPRINCFIELD . - VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRING FEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97677' Office: INSPECTION LINE: 726'-3759 726-3769 Job Location: 1.>;' I (P~ ~5$Q- ,<y ~L?() n ~ '17 c07 ~, Ta;: Lot ~: ()').IO).... " Assessors Map Ovner: 2. ~: 1'763 ;;V 'fd-. w~ (pO" _ _ _ '-e->> , I I Address: /.'1/ Phone: ~: I i./ ,- / 5 .~ 9 City:. ~ ~ - I - J'v Value of Vood Stove(tellet State: ()~~ Zip Code: o StoV';)Insert: l.iDO.DO "7' 7 <-IT7 Preliminary Inspection is $15.00 (pdor to installation of insert) Vood Stove/Pell~t!Insert Permit is $15.00 + $.75 state surcharge + $.65 administrative fee + S10.00 issuance = $26.20 total .' Type of Inspection Requested: (?.,pJ2f),,::!C ~ ~-fi:-, Contractor: I::k")/'")'(L 0LuJ1/lV" (~ Ah-JIA\ Add ress: " 5 I 'P ltMO-..Yt'+- s r ' Phone ~: Ci ty: ~12- State: T'l/2. Zip code: '17477 Construction Contractors Registration #: - Expires: - By signing .this pelomi t/application, I agree to call for inspection(s) as required (726-3769). I state that all the information on this permit/application is correct and .that I vas provided vi th the Vood 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 0{ Environmental Quali ty or the Federal Environnl(:!1ltal Protection Agency and I agree to provide the, tes t ing approval number to the inspec tor a t the time of ins pee t ion. I also understand that if I am requesting a preliminary inspection, the vall covering may be required to, be removed. /~ 'H. cJ~ I (t- I '(- '17 Date Sitnature ======================================================================================= FOR OFrICI; USE REQUIRED INSPECTION(S): VOODSTOVE~LET/INSE~ Date of Application: [[//1/97 y PRELIMINARY., Total Amount Collected: 2.6. :;C:o Job !I: 97/ ;Z3.5 Issued Ily: d~.4 ,/ /- Checked for lIistori.cal ~latus: ~ ~ . Receipt !I: ? ///"'2 , v '"Checked for Deliquencies: