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Real Property Address: ___________________________________________________________________________

The undersigned Owner of the above-referenced real property hereby certifies and declares that all noncertified woodstoves and fireplace inserts, including those specifically identified on the attached Disclosure Certificate, have been permanently removed from the buildings and structures on the above-referenced real property, said devices have been properly disposed of, as evidenced by the attached disposal receipt, and such devices shall not be replaced except with Oregon certified devices.

I, __________________________ the undersigned Owner, hereby declare under penalty of perjury and false swearing that I have read the foregoing document and that the statements hereon are true and correct.



State of Oregon


) ss

County of Jackson


The forgoing instrument was acknowledged before me on_________________________, by

______________________________________________, who represents that he or she is the owner of the above referenced property, or if the property is owned by an entity, represents that he or she is duly authorized by the entity to represent the entity is the owner of the property.

Notary Public for
My Commission Expires:

(Ord. 2936, added, 03/23/2007)