HomeMy WebLinkAboutPermit Mechanical 1999-7-23
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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
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Job Location: If /" I ' ( 1
Assessors Map #: I '7 a ~ ~ IJ 14-
Owner: /Joy!..:. M,rdt>i1e v
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Address: ~O) !refco!T
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City:, # -r pi State: 01'- Zip: c;? II ')? ~ (') g 0 % g ~
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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
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Issuance. . . -" -. ~ S _ '---" m 4.C'
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Tax Lot#:
OQ100
Phone#: '7 '-II - 2JJ I> 1
Type ofInspection Requested:
Contractor:
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Address:
Phone#:
City:
State:
Zip:
Construction Contractors Registration#:
Expires:
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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
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Signature // O' gj :Xl Z )>.
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REQUIRED INSPECTION(S): WOODSTOVElPELLETIINSERT
PRELIMINARY
Date of Application: 1- ~3- <; '"\
Total Amount Collected: $d.lD. ~
Job #:
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Receipt #:
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Issued By: -KtJ
Checked for Delinquencies:
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Checked for Historical Status:
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