HomeMy WebLinkAboutPermit Mechanical 1996-10-22
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SPRINGFIELD
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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City:
S;29S- ~~~r~~ ~~'/I-;,;;;--
Assessors Map ll: /7 -02- ;> f- "-icy' Tax Lot #:
O\Jner: ~r'~G ~t'~C8~~ /~ eeL-:>
Address: 5'2~,5' /c::?""~/~./'"'~ c;.-. Phone: #:
??A~ 'State: ~-)
Job Location:
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Zip Code:
72c:.........2d'~.
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Value of Yood Stove/Pellet Stove/Insert:
/5:j~, ~'eJ
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Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit i~ $i5.00 + $.75 state surch~rge +
fee + $10.06 issuance = $26.20 total
Type of Inspection Requested: ~~~~~ ~~~~
Cona-actor: ~u-~~"
$.45 administrative
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Address: '
Phone #:
City:
State:
Zip C;ode:
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Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for inspection(s) as required
(726~3769). I state that all the information on this permi~/ap~lication is ccirrect
and ,that I \.fas provided \.fi th theYood Stov<i Safety information for \.food burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke .emissiQn standards as set by the Oregon Department of
Envi~onmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at th€! time of inspection. I
,also underitand that if I am requesting a preliminary inspe~tion; the \.fall covering
may be required to be removed.
-Dt('J' ~.ud.
Signa tl,ll-e I)...f:.
Ii) - 22 '. q/.p
Date
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FOR OFFICE
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YOODSTOVE~L~NSERT
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-:26. .:< 6
USE
REQUIRED INSPECTION(S):
x
PRELIMINARY
Date of Application:
Job #:
~~/Y<Y
Total Amount Collecte9:
Receipt #: -::;;?'3Z~
Issued By: ....?~=
Checked for Historical ~t:s: . -,/'
~hecked for Deliquencies:
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