HomeMy WebLinkAboutPermit Mechanical 1995-7-17
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S~RINGFIELD
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Job Location:
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Assessors Map #: /7l'2..3 J1 ~
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Address: 4'f~ 2)A-t'S V
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'S"filA ~ . ,State:, ~-, _._Zip Code:
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Value of \lood Stove/Pellet Stove/+risert: / ~ ,/4 ,) -
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Preliminary Inspection is $15.00 (prior to installation of insert)
\lood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
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Tax Lot #:
t::;J I 74' tJ
Owner:
Phone:~
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~ 7~74,
City:
$.45 administrative
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By signing this permit/application, I agree to can--foY'.....i:n.s.pectioif(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided wi th the \lood 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 P~otection 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 be required to be removed. '
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Type of Inspection Requested: )C'~-I'_~~-- ~.~~~
Con !rac lnr' _.;:?'-f)z)'-(,,;;'~l1h ;XZ- ,~.
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Add.F,eS';: ' (? 7 n :2 3 I .I ve~--f 0-1\ Rd 0 E.
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CO;;S-H.uction Contractors Registration #: LJ9flL/Z
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Phone #: (50:1 ') :) "7f:tj>!)lf.. t.f
Zip Cpde: Ci750~ "\.
Expires: 4-//- 96 /
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FOR OFFICE USE
Total Amount Collected:
\lOODSTO~LLE~NSERT
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PRELIMINARY
REQUIRED INSPECTION(S):
Date of Application:
Job #:
cJc-L) / 22 ~
Receipt
#: JC!342-7 .
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Issued
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Checked for Deliquencies:
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Checked for Historical Status: