HomeMy WebLinkAboutPermit Mechanical 1996-9-27
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UOOD STOVE/INSERT INSPECTION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE; 726-3769
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Job Location: ~t:('-I-'~ C!....4~\ 1/U,4G
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Tax Lo t II:
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Phone: #:
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97 L/-7 7
Zip Code:
Value of Vood Stove/Pellet Stove/Insert:
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Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.Q5 administrative
fee + $10.00 issuance: $26.20 total
Type of Inspection Requested: U-f e...cI' ~/..e:f J>fJ tie /l1.Sh,tlvd? ~
Contractor: 'G-o~ (-))~ 1l1e+-a) '..fJr-o~ ~ -!--1vC---/ '
Address: ~d-~ 111 ~,0 ~<;/ Phone.~: ,/jt)~ -~ ~J-./
City:_S;Jt2ltOlfF/~D State: ()~ Zip Gode:Q7cL"rJp
Construe tion Con trac tors Registration #: ;Jt-, '743 Expires: J7"9 '7
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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 ",as. provided ",i th the \.Tood Stove Safety information for ",ood burning
appliances and preliminary inspec t ion standards. I further s ta te tha t the appliance
I am installing meets smoke emission standards as set by th.e" Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
'pr.ovide 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
ay :-eqUire~t~Q:w~ 9ft7/7~
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Date
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. OR OFfICE USE~
REQUIRED
Date of Application: .Qj _ .C\\p Job
Total Amount Collected: ~.OO
Receipt ff:A~X\
PR71IMINARY
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Issued DY:~~
'-Checked for Deliquencies:
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Chccked.[oriiistorical Status:".-