HomeMy WebLinkAboutPermit Mechanical 1996-11-19
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SPRINGFIELD
UOOD 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:
/2-'/7 . )~i,;.'i/~
/70-3-3 Cf2X
/~ .("en /-I/f?
/75 . ~7';-
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Uood Stove/Pellet Stove/Insert:
Tax Lo t r,: rrJ:21 ?5
Assessors Map ~:
Ol.lner:
,1{;;H~i<
Address:
Phone: g:
7'7/-:16~5'- .
97..,1'?
City:
State:
bI/l.
/, / IIi)
Zip Code:
Value'of
Preliriiinat.y Inspection is $l5.00 (prior to installation of insert)
Uood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: ~
~,45 administrative
Contractor:
Mt'~~ i34'''~/"}
/'Z?5 /h...-t m--
5/;~// .
J;.lt'6-1z/'wll~
Phone ~: 7Y'/-? rJ' ..),.-
Address:
CTX-
Construction Contractors 'Registration ~:~ Expires: /~f
By signing .this 'pet'mit/application, I agr~z.-,f"tall for inspection(s) as required
(726-3769). I state that all the information on' this permi t/applica'tion is correct
and .that I vas provided vith the Uood Stove Safety' information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing' meets smoke .emission standanJsas set by the Oregon Department of
Envi ronmen tal Quali ty or the Federal Envi ronn,en tal Pro tee t ion Agency and I agree to
provide the. testing approval number to the inspector at the time of inspection. I
also understand that 'f I am requesting a preliminary inspection, the vall covedng.
../ b, ""h',d " ~ . \/ //77-7-"
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Ci ty:
State:
Zip Code:
? .?y7;?
REQUIRED INSPECTION(S):
Date of Application: {-
LET /INSERT
Total Amount Collected:
,..,
2h,:J ()
Job ~:
PRELIMINARY,.
9b()tflfn
Receipt II: 23glf?
.-
Issued By:
~
'"Checked fot. Deliquencies:
Ulccked' for' "istoric~l Status: