HomeMy WebLinkAboutPermit Mechanical 1994-10-25
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: Lffo, \)a'l ~ ~ 5 T
Assessors Map #: //~~<- ~ ~
Owner' k~__a- (,,~ct5"'( "- J
Address: ~~t!5 - O.
City: ~~~ State: .c9~
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Tax Lot #:
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Zip Code:
6>~~- !>- r".2.~
7~/-7/2~~'
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Phone: #:
Value of ~ood Stov~l]:et Stove/Inser:D -2: ~~.. .-..:~
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Preliminary Inspection is $15.00 (prior to installation of insert)
~ood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
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Type of Inspection Requested:
Contractor:
Address:
Phone #:
City:
State:
Zip Code:
Construction Contractors Registration #:
Expires:
By signing this permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided with the ~ood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the wall covering
.may be reqUir~~oved.
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Signature !/ Date
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FOR OFFICE USE
REQUIRED INSPECTION(S): ~OODSTOVE/PELLET/INSERT
Date of Application: ./P~'Z.$"~V
PRELIMINARY,
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Job #:
9cr/6~9'
Total Amount Collected:
/ 7", (.Jo t2/
Checked for Deliquencies:
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Issued By: d--~
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Checked for Historical Status:
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Receipt #: /n~
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