HomeMy WebLinkAboutPermit Mechanical 1996-3-4
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STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
....
Job Location:
7L:J'77 ~.ffi~L/A ~
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Map #: //' ~ '2 -'5t5' - 3 ?
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State:~;:r.
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Assessors
Tax Lo t #: tt:!?S-/~
O\Jnel- :
Address:
-~,(' ?o//-372?
Phone: #: /~/-"'?2.//
5~-
Value of \,Iood Stov~enet St'ove/Inse~ /)~ c:ri!F
City:
Zip Code:
~?Y'?~
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 = $26.20 total
Type of Inspection Requested:
contractor:bC U~~~r' -,MP L'/~?/r~$(7f-
Address: 70. 2)~x "< 3~
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~~ State:
- , '/
Construction Contractors
Phone'#:
~5/-3.7'5"S--
97Y02- '
9/5-97
City:
~.
Registration #: 7~~~ Expires:
Zip Gode:
By signing this permi t/application, I agree to call for inspection(s) as required
(726-376~). I state that all the information on this permit/ap~lication is correct
and tha t I \Jas provided ",i th the \,Iood Stove Safety information for ",ood burning
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
Environmental Quali ty or the Federal Environnlcntal 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 \JaIl covering
may be required to be removed.
Signa tm-e
Date
---------------------------------------------------------------------------------------
----------------~----------------------------------------------------------------------
FOR OFFICE USE
REQUIRED INSPECTION(S): \,IOODSTOV~LET/INS~' ~
PRELIMINARY ,~/ t'~6.l>
#: ~~2-=7 /
Date of Application: "'- y-%
Total Amount Collected: ::;2&;- "'2~
Job
Receipt #: ~~~;r
Issued By, 4 ~
Chccked'for Historical Status:
'-Checked for Deliquencies: