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HomeMy WebLinkAboutPermit Mechanical 1995-6-25 . .. YOOD STOVE/INSERT INSPECTION CITY OF SPRING FEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: 726-3759 INSPECTION LINE: 726-3769 Assessors Map #: J7.-A~ -:7?-~'Z O...neL': TJ/pMAU=; ;:3/'-3 y"'S~.A;/ ; Address: /6,ffr? m6J0'/'7 ?7rz:'9- Value 0~60d Stov~Pellet Stove/Insert: ./,t:;i!50 ;P/!?e"5c~7T ?..~E Tax Lot #:~?5'~ Job Location: City: State: LA' - ~~ . Zip Code: /~......:=:. Phone: #: 7 "2&-/9Ji?/ "7' ;??E? '7 Preliminary Inspection is $15.00 (prior to installation of insert) Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative fee + $10.00 issuance = $26,20 total Type of Inspection Requested: ./:%IrE "~~/~ I~".~'? ~E . conu-actor:~~hI P ~.P~~' ,7{P/~q/~/I/?~ .~~ Address: -::? 2 / "1'0 ~C/ ~ 67; Phone It: ?t.//-~~ - i . . City: ~??~7j State: ~;;q. . Zip Cpde: q74/?~ Construction Contractors Registration #:)t'::3~.-=? Expires: /2....~-95"' By signing this permit/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 ...as provided ...i th the Vood Stove Safety information for ...ood burping 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 Environmen tal Quali ty or the Federal Environmen tal Protec t ion 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 inspection, the ...all covering may be required to be removed. I CO'2':f- .Q5 Date' =============================================================================== , " FOR OFFICE USE REQUIRED INSPECTION(S): ~DSTO~/PELLET/INSERT ~ PRELIMINARY Date of Application: 6'-?7'~ Job #: 1':::~:2"3 Total Amount collected: '26. -;;>- Checked for Deliquencies:. Checked Issued By: /2~.;~;-- for Historical ;~tus: ' Receipt #: /~