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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 Job j Assessors Map #0 aJ owner: J.^rvs CL^vK Tax Lot#: eaar"r' i3 *) Ov<-q A*,.-Phone#:FilA5 State: C€--. Value of Wood Stove/Pellet Stove/Insert: \ OOO (please circle appropriate appliance) -_f 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. L (o \/e(Type of Inspection Requested: Contractor: Address: S<.a*rt aa Phone#: City:€-s.----<-__-_-___])_ Constuction Contractors Registration#: State: OK 6tlzg 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 o#,c3b1a? D 4 f--^^.2\(s --e-xJ gv.-Jtn-<r/