HomeMy WebLinkAboutPermit Mechanical 1995-10-31
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\100D STOVEIINSERT INSPECTION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street Office: 726-3759
Springfield, Oregon 97477 INSPECTION LINE: 726-3769
Job Location: ~~S\oC)\OY\~ llQ(\\ ~\M,Q .venA
Assessors Map #: I~TO? ~ Tax Lot ~ CXXO I
0Ilner:~~\\0 R. . \bDst-lllOf) ~_UQ[)'-Q~
Address:BS\~\ 0\)~ () f\ ~ .' Phone: #:::I2J(1'~~lO I
City:~~~I7i. ~tate: M / Zip Code: Qi)4'70
Value of ~o(.\.s'tove/Pellet Stove/Insert; \\ r ) -
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20~tal,'
Type of Inspection ReqUested~\ .I
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Contractor:
$.45
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administra)
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Address:
Phone #:
City:
State:
Zip C;ode:
Construction Contractors Registration #:
Expires:
By signing this permi tlapplication, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I lias provided IIi th the Vood Stove Safety information for lIood 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 Quali ty 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 lIall covering
,r:b.:;:~_:'.~ ~.:11. 19Q5-
~ure Date
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Checked for Deliquencies:
Checked
PRELIMINARY ~
Job #: q ~\~\~~
I",.d ,J~(. .
for Historical Status:
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOV~LLET/INSERT
Date of Application: 10.8/.'-1:::5
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Total Amount Collected:
Receipt #: \ GN...fl/