HomeMy WebLinkAboutPermit Mechanical 1993-3-3
- SPRINGFIELD
~
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 72~~3769
Job Location: "7 ~ 1... 9 Holl.. H..
"
Assessors Map#:l~DL- 02.. 74
Owner: JA"- \) \~ L
Address: "71- L '7 He.> \ \"
City: s;> (l.)~, he \~. State:
Value of Vood Sto;e/~let St~/Insert:
(please circle apy.~y.l~~e appliance)
Tax Lot#:{) lasD
/
Phone #: ,')..(.- I) yO
Or"L Zip:-5,u 1Y
, 5 0ll,gl2.
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 Request~d: \V\~~cJj~ll';"
Contractor:
Se.\+."
Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
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
may be required to be removed.
Signa ture'1- a I Jl
1-3-~)
Date
FOR' OFFICE USE
Date of Application:
VOODSTOVRZPELLE~SERT
~ - t.} "17..--
~ PRELIMINARY
Job #: Uf7 j)~ i~
REQUIRED INSPECTION(S):
, -
Total Amount Collected: 2..f].. 7c::,
Receipt #: ?::ft 0 ~ Issued By: ~\fV'o n
Checked for Delinquen.cies: ~ Checked for Historical Status: ~