HomeMy WebLinkAboutPermit Mechanical 1992-01-10CITY OF
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 rlfth Street
Springfield, Oregon 97477
0fflce:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Map #:
-3 Tax Lot *z C
Owner:
Address:Phone #:
Ci ty:State:rfl-Zipz 1
Value of llood S /Insert:
(please cir te appliance
Prellminary Inspection is $15.00 (prior to installation of insert)
lJood StoveTpeUet/Insert permit'is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspection Requested:
Contractor:M
Address:ZZ :-
Phone #: /
state: dY-z1 p!
/ t. c?zt/ -,/a - rz
Ci ty:
Construction Contractors Registration *, ? b*/t13 ,xpires:
By signlng thls permit/application, I agree to caII for an inspection(s) as requlred
<iZO-|lOg5. t siate tt.i-aII lnformatlon on this appllcation/permlt is correct and
ifrat f was provlded with the llood Stove Safety lnformation for wood burnlng
appliances and prellminary inspection standards. I further state that the appllance
I'am installing meets smoice emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing .pproral number to the inspector at the time of inspection. I
also understand ttrit it I am requesting a prellminary inspectlon, the vaII coverlng
u1 removed.
gnature ffi--
FOR OFFICE USE
llet/
REQUIRED INSPECTI0N(S): !I00D
Date of Application:L
Total Amount Collected:
q1
PRELIMINARY
Job S:1>oook
Receipt *:
Checked for Delinquencies:
o
Issued Byt
Checked for Historical Status2-:-
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CITY OF O'U
TIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIETD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SP'I!'tGFIELD
0fflee:
INSPECTION LINE:
726-3759
726-3769
Job Location: I
Assessors Map *:
Ovner:
P
II,
Uq 6-a*
'27o)z
(,
ii
v Tax Lot *:
Phone *:Address:
Ci ty:State:6E-
Value of llood Stove/Pe11et Stove/Insert:
(please circle appropriate applianc[
zip:
iminary Inspe ction $15.00 (prior to installation of insert)
Permit'is $15.00 + $ .75 state surcharge + $10.00 Issuance.
rp liwt
rt
Type of Inspectlon Requested:
contractor: Alittr.-.-
a-.
Address:Phone *:
Citv: State:z1 p3
Construction Contractors Registration #:ires:
By signing this permit/applicatlon, I agree to caII for an inspection(s) as required
<iZO-hegt. I state tt.t-aII information on this appllcation/permlt is correct and
ifrat f vas provided wlth the llood Stove Safety lnformation for wood burning
appliances ind preliminary inspection standards. I further state that the appllance
I im installing meets sroic" emission standards as set by the 0regon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing lppro.ral number to the inspector at the time of inspection. I
also understand ttrat ii I am requesting a prellmlnary inspectlon, the vaLI coverlng
may red o removed.
t-b -?z-
ure Date
FOR OFFICE USE
REQUIRED INSPECTION(S) : V00DST0VE/PELLET/INSERT
Date of Application:t*b 4z
Total Amount Col}ected:t 5. d7)
Recelpt #:Issued By:
Job *:9?-DcD?
Checked for llistorical Status:
U
Checked for Delinquencies z --t.1-