HomeMy WebLinkAboutPermit Mechanical 1992-04-16CITY OF oREqofu
SP'II,{GFIELO
Offlce:
INSPECTION LINE:
%IIOOD STOVE/INSERT TNSPECTION APPLICATTON
CITY OF SPRINGFIBLD
BUILDING SAFETY DIVISION
225 rtfth Street
Sprlngfield, 0regon 97477
726-3759
726-3769
Job Loeation:O r Sl,
Assessors Map *:fl Dz;aLq rax Lot *: C21 OA
0vner:
Address:
may required to
ture
Phone f:
,7
Ci ty:State:Zi p3
VaIue o st Iet Stove/Insert:fuoa - oz)
(please clrc appropriate appliance)
Preliminary Inspection is $15.00 (prior to installatlon of insert)
Uood Stov"Tp"ttltllnsert Permlt'is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspectlon Requested:{-,,L<SM
Contractor:
Address: Phone #t_
Citv: State:zip:
Construction Contractors Reglstration #: Expires:
By signing this permit/applicatlon, I agree to call for an lnspection(s) as requlred
<iZO-hegt. I siate tt.l-aII information on this appllcatlon/permit is correct and
inat f was provlded wlth the Wood Stove Safety lnformatlon for wood burnlng
appllances and prellmtnary inspeetlon standards. I further state that the appliance
I'am lnstalling meets smoke emission standards as set by the 0regon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing .pprorql number to the inspector at the time of inspection. I
also understand ttrit ii I lln requesting a prellminary lnspectlon, the waII coverlng
ffU
?-to />-
Date
rOR OFFICE USE
REQUIRBD INSPECTION( S) :
Date of Application:
Total Amount Collected:
Receipt *:
/INSBRT t"'- PRELIMINARY
Job #:
Issued By:
VChecked for Delinquencies:Checked for Illstorical Status:
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