HomeMy WebLinkAboutPermit Mechanical 1994-11-02u46
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SPRINGFIELD
0ffice:
INSPECTION LINE:
tz6-3759
726-3769
CITY OF SPR OREGO'V
q r),q,,= SJob Location:
Assessors MaP *:
Ovner:
4 =?-Tax Lot #: A?
Phone z *z '74 )-)roo
Zip Code I q>Lt 77
Address: CIS q C,a,<[)n..I
Ci ty:Soo,a.] \. r-r(gr-t')
Value of Vood St
State:
L>^at,) --
PrelirninarY InsPection is $15
Uood Stove/Pe11et/Insert Perm
fee + $10.00 issuance = 526'2
Type of InsPection Requested:
.00 (prior to installation of insert)
ii"ii'sri.oo-* $.25 state surcharge + $.45 administrative
0 total-
+
Contractor:
Address: 57 sfl 1,r-R ^rS Phone *:r -o
Ci ty:(.E-l-Je State:r(zip Code: q
Construction Contractors Registration +; ?s.s- S. I Expires:
By signing thi.s permi t/aPP lication, I agree to call for insPection()as required
(726-376e).I state that a II the information on this Pe rmi t /apPIi cat ion is correct
and that I vas P rovided vi th the Vood Stove Safety info rmation for vood burning
app liances and Pre liminarY inspec tion standards.I further state that the aPPl lance
Iam installing me ets smoke emis sion standards as set bY the Oregon DePartmen tof
Environmental OualitY or the Federa I Environmental Protection AgencY and I agree to
prov ide the testing a proval number to the insPeet or at the time of inspec t ion.I
also understand that
Pif I am reques ting a PreliminarY inspection, the valI cover ing
may be required to be removed.
lgna
Yl
REOUIRED INSPECTION(S): V00D
Date of APPIication:
Total Amount Collected:
Receipt +, /?727 .
ate
OFFICE USE
u--
PRELTMTNARY
Job *:
Issued BY:
A
=================--=======
7-7r
S tove/Inseret
/INSERT
Checked for Deliquencies:
2o
FOR
Checked for Historical Status:
Ar-r *(65[
(o c/(.Y
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