HomeMy WebLinkAboutPermit Mechanical 1993-11-12
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location:
~5$ CleaR.~ue.. ~.
Sp~(\)'\telcl DlL
Assessors Map #: r:r
SPrlUd~r-r
Address: G~")S CIeap.~Ue..
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O"ner:
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JeAt0 Steohel\)~
Tax Lot #:
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04)OD
LN,
City:
State:
Phone #: ct4\o - 1\\ J
OlL Zip: qll\;l.~
4 2.:lClD 00
Value of Vood Stove~ellet Stove/Ins;?r,!
(please circle appropriate appliance)
Preliminary.Inspection is $15.00 (prior to installation of insert)
Vood Stove/P~llet/Insert Permit is $15.00 + $10.00 IssGsnce + $.'5
Type of Inspection Requested: ~\\lY\'\(\)~'1
Con t rac tor: \he. (' ~ Sh,'{lG Le~\-eIL
W. (o~
state surcharge.
Address: \& ~'i;
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Construction Contractors
City:
State:
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Phone #: 4c~S- - ~~~
Zip: Ql%-z...
_Expires: III -LX -<}L\-
Registration #:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I "as provided "ith the Vood 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 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 "all covering
may be required to be removed.
~~~
Signature
\\-\2..-9""\
Date ./
FOR OFFICE USE
REQUIRED INSPECTION( S): VOODSTOVF(PiLLET~~RTJ L---- PRELIMINARY l
Date of Application: /// S-/5' 3. Job #: 9.~/ 1:-32-
Total Amount Collected: ~t:).j7~
Receipt #:
/rJ9t91)
Issued By:
~~/'-4
-q;-
Checked for Historical Status:
Checked for Delinquencies:
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