HomeMy WebLinkAboutPermit Mechanical 1991-12-24OBEGOfUCITY OF SPR D
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Offlce:
INSPECTION LINE:
IIOOD STOVE/INSERT INSPECTION APPLICATTON
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Ftfth S.treet
Springfield, 0regon 97477
726-3759
726-3769
Job Location: iO;':u0u$u^ S-}',
Assessors Hap #:t1 -0 > -3a-77
Owner:to
Tax Lot fi:h*tc0
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+Phone #:1H,-Ll'7 /8Address:t0 73 u)a Plr'
Ci ty:State 3 zip:
Value of let Stove/Insert:
(p appropriate appliance
Preliminary Inspection is $15.00 (prior to installation of insert)
lJood StoveTp"ttltZlnsert permit ls-$15.00 + $.75 state surcharge + $10.00 Issuance.
Type of Inspection Requested:
Contrac tor:
Address:Dox Y3>Phone *:s
Ci ty:boc State: m(zi p:Qt4t4
Construction Contractors Registrat ion #: S}jctI ires: I
By signing thls permit/application, I agree to caII for an lnspection(s) as requlred
(726-3769). I siate thai-aII informati6n on this appllcatlon/permlt is correct and
inat f was provlded vlth the llood Stove Safety lnformatlon for vood burnlng
appliances and preliminary inspection standards. I further state that the appllance
I am installing meets sroice emission standards as set by the oregon Department of
Bnvironmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing "pproual number to the inspector at the time of inspection' I
also understand that if I am requesting a preliminary inspection, the wall coverlng
may be required to be removed.
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FOR OFFICB USE
REQUIRED INSPECTION( S) : 1IO0DSTOVE /PELLET/INSERT PRELII.IINARY
Job #:9 t \8.0Date of Application:
Tota1 Amount Collected:
Receipt *:
1s
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Checked for Dellnquencies:
Issued By:
Checked for Hlstorical Statusr- .--
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