HomeMy WebLinkAboutPermit Mechanical 1994-9-12
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
Job Location:
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Assessors Map #: 11 b Z3,cJ L/ L/
Owner: K ~ b eJr1- l \ V\.U
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Value of ~ood Stove/Pellet Stove/Insert:
Preliminary Inspection ~l~(prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
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Tax Lot
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State: t5r
Phone: #: 7lft:; -S?8CJ
Zip Code: ,17'173'
Address:
$.45 administrative
Type of Inspection Requested:
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Contractor: O~
Address: Phone #:
City:
State:
Zip Code:
Construction Contractors Registration #:
Expires:
By signing this permi 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. was provided wi th the ~ood Stove Safety information for wood burning
applia~ces and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection 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 wall covering
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Signature ~ Date
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FOR OFFICE USE
Date of Application:
~OODSTOVE/PELLET/INSERT
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PRELIMINARY
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REQUIRED INSPECTION(S):
Job #:
Total Amount Collected:
Receipt' #: i L-\ (0 l fr.
Issued By:
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Checked for Deliquencies:
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Checked for Historical Status: /