HomeMy WebLinkAboutPermit Mechanical 1994-4-19
VOOD STOVE/INSERT ,INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
~D'
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: /670 4&~J ~/~,.o ~...d
Assessors Hap It: \ I\~~ Tax Lot It:
Owner: ~h.A?A"'d /"' dlf?,-/F,J
Address: /S-7~ ~/...#""'J ..&o/~P ~/ Phone It:
City: _,YPh'7h,e>/J State: tOAf7,c
Value of Vood Sto~e~:~~et Stov (in~~: /~~-~
(please circle a late a~lance)
~
()i['iX )
77''7- .y~Y'tf'
979:7;:::'
Zip:
Preliminary.Inspection is $15,00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.15 state surcharge.
Type of Inspection Requested: ~(.>;/D~ ~ ~& ~~;r--
Contractor: ~""'J~~~/~
Address:
Phone It:
City:
State:
Zip:
Construction Contractors Registration It:
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 ~qU~d to be remove~,
~,<~;/ / ~-VA../
Signature ; v7
Date
FOR OFFICE USE
REQUIRED INSPECTION(S):' VOODSTO~ET;INS~ ~ ~RELIHINARY "?:
Date of Application: 4',\C\_,~ Job It: C\4>~
Total Amount Collected: 40' ~S ~ I -
Receipt #: \~.?/IIf- Issued By:C/ \~~ )
Checked for Delinquencies: Checked for Historical Status: