HomeMy WebLinkAboutPermit Mechanical 1992-7-28
SPHINO"-IELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S,treet
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: )726-3769 t-
Job Location:~1'1~ncf2 S-lAio-f
Assessors Map D: 1/ Q~:S I.J 44
Owner: :f.u ('PIA i,~ ' J1p .i h 0 ~
Address: 1",9.4-t..J- ~rld"1f')od ~,
City: ~\~U{'Q State: 1")0
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
Tax Lot #: GOI IS
Phone #: ~';).."",:J.fr, I 2
Zip: c:nLf 75<
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
,Type of Inspection ReqUested:~/.P!~\ r\("'JrO ~ \,)Jls. ~L
Contractor: .
Address:
Phone i:
City:
State:
Zip:
Construction Contractors Registration D:
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 Vood 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
V A: '~.i;:&/ '/"./""
'fiigna ture ,/ (/' Da te
FOR OFFICE USE
REQUIRED INSPECTION(S): 1l00DSTOVE/PELLET/INSERT PRELIMINARY yo
Date of Application: "7/ ::JS?\C\'l Job #: \ Q:;;}l()3./ /
.!l> \ S-. DO /
Total Amount,Collected:
~
Receipt i: ~JJ:1 Issued By: <i::J~
Checked for Delinquencies: Y Checked for Historical Status: Y