HomeMy WebLinkAboutPermit Mechanical 1992-8-28
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
U6b
225 Fifth S,treet
Springfield, Oregon 97477
Job Location: &.f~5 ~/~/ ~
Assessors ~ II: I f) 03'J~~
Owner: C::\Jer"-l -2 kef/If ~UI1I'1
Address: ,.;;d!.; 5 (j/-,{) red;uu ~
Ci ty:' \....'l./;/rd,
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Value of Vood Stove/Pellet Stove/Insert:
'(please circle appropriate appliance)
Office:
INSPECTION LINE:
726-3759
726-3769
,JJp/cL & 91A/11
I /TV) I) f""oI )
Tax Lot II: l rl.t( U
Phone II:
'1"// -J'..3 Jj;j.
Zip: C/7'417
State:
~
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Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permi~,.~$15.00 +. $ .75 state surcharge + $10.00 Issuance.
Type of Inspection ReqUested~ \ 0 ~ 'l f'{\
Contractor:
Address:
Phone II:
City:
State:
Zip:
Construction Contractors Registration II:
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 Yood 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
o und and that i~~:d~equesting a preliminary inspecti~njY the/wall covering
may ui I~o be r~t~U 1~8'192
SIgila tIre' : "j-, Da te
'- ~ FOR OFFICE USE
Receipt II:
Collected:
lo~
_, A
~PRELIMINA~
0),~.q!:L . Job II: -q cG \\qL1"
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Issued BY:~(_~ _ ~
VOODSTOVE/PELLET/INSERT
REQUIRED INSPECTION(S):
Date of Application:
Total Amount
Checked for Delinquencies:
(jl
(
Checked for Historical
Status: ~
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