HomeMy WebLinkAboutPermit Mechanical 1999-12-29
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SPRINGFIELD
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
4
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AMT RECD:! $ 26.50
CHANGE:
CASHIER:QOl
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: <:2-~ S
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Assessors Map #: /?~"'Z...;? '.:3 ~ q
Owner:~ ~ ~ A Q..O{ f' t.~ vV
Address:c-t2.. 9 ~ (', Y b r-.A /' f1..
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Tax Lot#:~/o~
City: C' IP Y"{)
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Value of Wood Stove4[ellet St~;nnsert: / 'A 5'P ~
State:
fZ)/((C
Phone#: ?~b - Y5~'
Zip: 5! 9417 ~
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPellet/Insert Permit is $15.00 + l.OS state surcharge + $.45 Administrative Fee + $10.00
Issuance.
Type of Inspection Requested: ? C:C:tC;t>T ~y &
Contractor: ~#~~
Address: Phone#:
City:
State:
Zip:
Construction Contractors Registration#:
Expires:
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 was provided with the Wood Stove Safety
information for wood 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 n,umber to the inspector at the time of inspection. I also Understand that if I am requesting a
preliminary inspection, the wall covering may be required to be removed.
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FOR OFFICE USE
Signature
/'2- - 2.. ?-719
bate
REQUIRED INSPECTION(S): WOODSTOVE~SERT
Date of Application: /::;f....:z... ~ ~ 9e:::? Job #:
V PRELIMINARY
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Total Amocn. Co II ,,"d::;;z.6 . "5.:> R"cip. #: U'Y I"ood BY:'l~- ·
Checked for Delinquencies: Checked for Historical Status: