HomeMy WebLinkAboutPermit Mechanical 1994-10-25
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~OOD STOVE/INSERT INSPECTION ApPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: ifot./O e.AR..:iE.fL
Assessors Map #: 17 D ~ (;.F7 ? 2.-
Owner: p& '1<" ct. C,v..J<:.J (, I Jo o"c.'::'ll
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Address: (Co l{O c.A.R....-TE/7 Phone: #:
City: Qp/tlNc..r-It:SL,() State: n Zip Code:
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Value of ~ood StoveC!ellet StovelI~ 7_ ') ?I'~
Preliminary Inspection is $15.00 (prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of In6pection Reques~ed: PILE (( t::A.,JAt. t:Ol'l fill ASo~\~ t=/~
contractor/(4CPf..!. (JJE6JJ1JP~ GA1~~I/~) t
Address: S7c- LtJIL~) I -, Phone #: Co~(-CRCo~
City:~':,J.'.H....,~('\h.lGaJE. State: r1 Zip Code: q)<tD4
Construction Contractors Registration #:$S-S{ Expires: I?JqcJ
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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 was provided wi th the ~ood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets "SlJlOke 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 L am requesting a preliminary inspection, the wall covering
may be required to be removed.
Tax Lot #:
l '50 (X) ,
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Sig~~~ '';.? ,!Jate l" '
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FOR OFFICE USE
VOODSTOV~LE;;~:~~
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Date Qf Application:
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PRELIMINARY
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Job#:
REQUIRED INSPECTION(S):
Total Amount Collected:
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Issued By:
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Receipt #: l62L~
Checked for Deliquenciei:
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Checked for Historical Status:
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