HomeMy WebLinkAboutPermit Mechanical 1993-08-20ctfY oF OREGO'V
LIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Pifth Street
Springfield, 0regon 97 477
SPFI}.GFTELD
Offi ce:
INSPECTION LINE:
c6b
726-3759
726-3769
Job Location: 3h5 o 5
Assessors Hap #' I I (1'Z l"ctz I Tax Lot *:0rolb
0vner:R.t cha,,yl tlay v tSOt4
Address 3Z flt[nvt bol lo Phone *: lzlo -q bo
Ci ty:state: 0 f(zip ,q1q 11
Value of lJood Stove -laqq oo
(please circle appropriate ce)
Preriminary rnspection is $15.00 (prior to instarration of insert)llood stove/Perret/rnsert permit is 915.00 + glo.oo rssuance * $.15 state surcharge.
Type of Inspection Requested:
s\ar* Ct rt \u.Con t rac tor :
Address, lg15 W lo*h Phone *:4re -os3
Ci ty:State:5TL 4tZipz o
Construction Contractors Registration *:Ll b5b{Expires ,bLgLq S
By signing this permit/application
(726-3769), I state that all infothat I vas provided vith the llood
appliances and preliminary inspectI am installing meets smoke emissi
Environmental Quality or the Federprovide the testing approval numbe
also understand that if I am reque
may be required to be removed.
6 lognatureDate
FOR OFFICE USE
,1 I agree to call for an inspection(s) as required,rmation on this application/permit is correct and
Stove Safety information for vood burningion standards. f further state that the appliance
on standards as set by the 0regon Department ofaI Environmental Protection Agency and I agree tor to the inspector at the time of inspection. I
rsting a prelirninary inspection, ttre viII covering
I
REQUIRED INSPECTI0N(S): II00DST0VE/LLET
Date of Application:
Total Amount Collected:
Receipt $:,4 I
PRELIMINARY Y'
Job *:qi\A
Checked for Delinquencies:
I ss ued By:
Che for Historical Status:
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