HomeMy WebLinkAboutPermit Mechanical 1993-05-19C;ITY OF OREGO'I'
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SPBIi.GF!ELD
0ffice
INSPECTION LINE
59
69
Job Location:3
Assessors Hap *:/7 03s 5 z/Tax Lot *: 2ZO o
Ovner:
Address, //)3,{ A/;a AT Phone *:
Ci ty:
Value of llood Stove/pellet S
(please circle appropri
Type of Inspection Requested:
State:
tove/Insert: ^ .-"9.?
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state surcharge.
s?3/d
ate appliance)
Preliminary rnspection is $15.00 (prior to instarlation of insert)
IJood stove/Perret/rnsert Permit is 915.00 + $1o.oo rssuance + $.15
Contractor:
Address:o Phone *:A?o3 - \Z/o
Ci ty:hlc-State z 41_Zip:?7/e>
Construction Contractors Registrat io" n, #{OS Expires:
By signing this permit/application, I agree to caII for an inspection(s) as required
QZ6-176gt. I siate that-all information on this application/permit is correct and
in"t f vas provided vith the llood Stove Safety informatlon for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets sroke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing aPproval number to the inspector at the time of inspection' I
also understand that if I am requesting a prelirninary inspection, the vall covering
may be req uired to be removed.
3
S ture Date
FOR OFFICE USE
REQUIRED INSPEC] ION(S) :SERT PRELIMINARY
Date of Application:-/?-?3 Job *:
Total Amount Collected:?5
Receipt *:SS L rssued By:
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Checked for Delinquencies:Checked for Historical Status:
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