HomeMy WebLinkAboutPermit Mechanical 1995-11-6
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\lOOD STOVEIINSERT INSPECTION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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State: C') ~ Zip Code: C(rYI7
Value of IJood Stove/Pellet Stove/Insert::;l_ ~. ?f2rcC~)
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Preliminary Inspection is $15.00 (prior to installation of insert)
IJood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Job Location: '2'5 'Ss Ot.?11Z.\f lJC LAJ
Assessors Map #: 170~ ::2.7 12- Tax Lot
O\lner:~CH.IG-:1; \'~~",-A S~ol{::",
Address: 2- 'S '""S.c- a ~ V..:'-l \.J cC L/\./, Phone:
City: S?
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Type of. Inspection Requested:
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Contractor:
Address:
Phone #:
City:
State:
Zip C;ode:
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 tha t I \las provided wi th the IJood Stove Safety information for \lood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Departmenf of
Environmental Quali ty or the Federal Environmental Protection Agency and I agree to
provide th ting approval number to the inspector at the time of inspection. I
also un rsta that if am requesting a preliminary inspection, the wall covering
may b requ ed to~. b~. _~mo e~
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Signature~ - Date
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FOR OFfICE USE
Date of Application:
/
IJOODSTOVE/PELLET/INSERT
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PRELIMINARY ~
Job #: 95"/75'5'
REQUIRED INSPECTION(S):
Total Amount Collected:
Checked for Deliquencies:
Checked
Issued By: #~
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for Historical Status:
Receipt #: /5'5/6