HomeMy WebLinkAboutPermit Mechanical 1999-11-12-a
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Sheet
Springfield, Oregon 97 477
SPRII{GFIELD
Office: 726-3759
INSPECTION LINE: 726-37 69
CITY OF OREGO'V
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Assessors Map #0 aJ
owner: J.^rvs CL^vK
Tax Lot#:
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State: C€--.
Value of Wood Stove/Pellet Stove/Insert: \ OOO (please circle appropriate appliance)
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Preliminary Inspection is $15.00 (priorto installation of insert)
Wood Stove/PelleVlnsert Permit is $15.00 + t.o3 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
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(o \/e(Type of Inspection Requested:
Contractor:
Address:
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Phone#:
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Constuction Contractors Registration#:
State: OK
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By srgning this pennit/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 Wood Stove Safety
information for wood buming appliances and preliminary inspection standards. I further state that the
appliance'i am installing meets smoke emission standards as set by the Oregon Deparftnent of
Environmental or the Federal Environmental Protection Agency and I agree to provide the testing
approval at the time of inspection. I also understand that if I am requesting a
wall may be required to be removed.
Date
FOROFFICE USE
REQUIRED INSPECTION(S):WOOD STOVE/PELLET/INSERT
lUZ.1q ts5Job #:Date of Application
Total Amount Collected:Issued B
Checked for Delinquencies
50
Checked for Historical Status:
ARY
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