HomeMy WebLinkAboutPermit Mechanical 1999-02-18,
SP'IINGFIELD
0fflce:
INSPECTION IINE:
mI.IOOD STOVE/INSERT INSPECTION APPTICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, 0regon 97477
726-3759
726-3769
CITY OF OFEGOTU
Job Location:
Assessors Hap *; i7a3 >\ S*( Tax Lot *:lo/oo
0wner:
Address z /f-A / )f ,;il -O],*U aw req*tres llC'.; ' .:
Ci ty:State:
n tJtiiiit
N n Center. Those rules are set ft;i
952-0il
0090. You may obtain copies of the rules i;
calting the center. (Note: the telephone
number for the Oregon Utitity Notiticati*r,
center is 1 -B0et-33?-2344).
zip:?r4s r
Value o d PeIIet Stove/Insert:00
(pI ease c ircle appropriate appllanee
Preliminary Inspection is $15.00 (prior to installation of lnsert)
llood StoveTpettlt/Insert Permlt is $15.00 + $.75 state fil*t+#H,: + $10.00 Issuance.
Type of Inspectlon Requested: - 'i.r';lli l)i.iirlillr SF|ALL EXPIFIE lFTl-lE WORP'
},iJTIIOBI;IilN UNDER THIS PERMIT IS NOT
Cont rac tor:
Address , P.n. tox g *:
Ci ty:0",ffi-State: Ot,
Construction Contractors Registration #:73 rue _Expires:
S ture Date
FOR OFFICE USE
By signlng this pernit/application, I agree to call for an lnspection(s) as requlred
<iZO-|tOgj, I state tt.i'aII information on this applleation/permit ls correct and
inat f vas provided wtth the llood Stove Safety lnformation for vood burnlng
appliances ind prellminary inspection standards. I further state that the appllance
I'am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing ipproval number to the inspector at the tlme of inspection. I
also understand ttrat it I am requesting a prellminary inspectionr the vaLl coverlng
may be required to be removed.
I -B-rq
RBQUIRED INSPECTION(S) : II0ODST0VE/PELLET/h/ooJcfrrt PRELIMINARY tZgzildETtV
Date of Application:l,
Total Amount Collected:{r. >a
Receipt *:t))>1 ot
Job #, ff 6L?zf
/ Pr,,"t
Checked for Delinquencies:
Issued By:
Checkbd for Historical Status:
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