HomeMy WebLinkAboutPermit Mechanical 1993-07-09CITY OF OFEGO'V
I*IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPFIl{GFtELO
0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Hap *:Tax Lot *: D2z:>
0vner:
Address:
Ci ty:
Value of llood Stove/pellet St
(please circle appropria
Phone *:
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Preriminary rnspection is S15.00 (prior to instarration of insert)llood Stove/Perret/rnsert permit is 915.00 + g1o.oo rssuance + $.1g
Typer of Inspection Requested:
Con t rac tor:
Address:
Ci ty:
Construction Contractors Registration *, <7ZZ Expires:
state surcharge.
P 7 r: Phone yaTlFr2
State:zip:=>*2/?3€>
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 correci andthat I vas provided vith the llood Stove Safety infoimatton for vood burningappliances and preliminary inspection standards. I further state that the applianceI am installing meets smoke emission standards as set by the oregon Departme;i ofEnvironmental Quality or the Federal Environmental Protection Ag-ncy ana r agree toprovide the testing approval number to the inspector at the time of inspecti6n. Ialso understand that if I am requesting a preliminary inspection, the vill coveringmay be required to be removed.
S ture e
POR OFFICE USE
Date of Applicationz V,441'= Job * z ?-f - 7
Total Amount Collected 2 2r. >;
Receipt $:q4{1 Issued By:
v//-Checked for Delinquencies:Checked for Historical Status: