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HomeMy WebLinkAboutPermit Mechanical 1999-7-23 . . 't ~ . . SPRINGFIELD WOOD STOVEfINSERT INSPECTION APPLICATION CITY OF SPRINGFIELD COMMUNITY SERVICES DIVISION - BUILDING SAFETY 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 DO/ .Ire.r G6-+-r"' Job Location: If /" I ' ( 1 Assessors Map #: I '7 a ~ ~ IJ 14- Owner: /Joy!..:. M,rdt>i1e v ~ I Address: ~O) !refco!T f 1.'/' p o:;.Z.... City:, # -r pi State: 01'- Zip: c;? II ')? ~ (') g 0 % g ~ I ~ 3~~~~~~ Value of Wood Stov~:J Z 0 "15" (please circle appropriate appliance~ ,g' g ~ g S ~ P I.. I .. $1500 (p' .' II' f' ) ~ Q g 3 6 ~ m e, re Iffimary nspechon IS . rlor to msta ahon 0 msert _ _ n Q) 0 CD Dl ~ Wood Stove/Pellet/Insert Permit is $15.00 + 1,05 state surcharge + $.45 Administrative Fee + $10,00;. ffi ~ ~ ;; ~ g- t . .. no-ao~~n Issuance. . . -" -. ~ S _ '---" m 4.C' -))CD. -'o-'a.c ::>'g "2:1 :of g a"~ ?:3og....(/)'<o.' '..vCm-g.gmg:~ ~~~CD(02t'D-, '. =1-' :r (/) :r CD 02 _" - <t> 0 0 Ul ~ c: ~ Z - .... )> (1)-, E:o~g:D~(Om __m_ _o(/) :>: '"<0'":1 o.-g. 2 01 ~ c: C5 ~O-I\)__c g'ffi~gQ~~ ::J C"....._ ~ . ~ Tax Lot#: OQ100 Phone#: '7 '-II - 2JJ I> 1 Type ofInspection Requested: Contractor: ow YUJ'L.- 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 Wood Stove Safety information for wood burning appliances and preliminary inspection standards. I further state that the appliance 'j am installing meets smoke emission standards as set by the Oregon Department of . ~ 8 e: :I! 2: Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing -< :s:: :2 (j) S approval "umber to the inspector at the time of inspection. I also understand that if I am requesting a ~ ~ 5:l ;:R 0 preliminary inspection, the wall covering may be required to be removed, 0 Z N :Xl m ~ (") hi :s:: .. .L/",y( M~ D2ate3 JA/, 17 :0 g g ~ Signature // O' gj :Xl Z )>. (/ FOR OFFICE USE 0 en ~ F !Ji!jj:Xl!;';! )>:I!" Z-- o(j):Xl O"m zm;:; [!3~:I! -n=lm O(j)::E :XlzO ~5! REQUIRED INSPECTION(S): WOODSTOVElPELLETIINSERT PRELIMINARY Date of Application: 1- ~3- <; '"\ Total Amount Collected: $d.lD. ~ Job #: qq o qq ~-- Receipt #: 3tfi~ Issued By: -KtJ Checked for Delinquencies: ./ Checked for Historical Status: /'