HomeMy WebLinkAboutPermit Mechanical 1993-3-19
,SPRINGFIELD
WOOD 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: /31 g ~ 1\~ vJ60IL
Assessors Map #: \ 'lO 3 B () 3 ~
Sf-UNY ~~
1 ? 7 f ()J tion- /,IJo-f) ~
~dL_ ,_ State:
Value of \lood Stov~t S~Insert: J!;2,ooo tf'O_
(please circle appropriate appliance)
City:
(')J0
Tax Lot #: ()9,OcD
\)H r ~ ~
Phone #: '7Lf7/3;Q3
Zip: q71f77
Owner:
Address:
Preliminary Inspection is $15.00 (prior to installation of insert)
\lood Stove/Pellet/Insert Permi t is $15.00 + $10.00 Issuance +, $.75
Type of Inspection ReqUested: ~ ~J\ Q \.lA'f\ ~
Contractor: C\ X'd +)'- ~ ~~
Address: m It: - 6f 8 '0') - ;'f\ n ^
City: WQ~ State: l)()lJ(
Construction cont\Jctors Registration #: ~
state
-
Phone #: '(o8-3~391 ()
Zip: q-wW .
~n. ~R.~
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 \lood Stove Safety information for wood burning
,appliances and prelimi~~ry 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 wall covering
may ~e required to ~e remove
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lignature
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II
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): \lOODSTOV
Date of Application: (~. c:r
,
PRELIMINARY c., /'J
q?ffilo~
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Total Amount Collected:
Receipt #: f/?5q ,ued
Checked for Delinquencies:
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