HomeMy WebLinkAboutPermit Mechanical 1996-03-21UOOD ST(IVD/INSERT INSPECTION APPLIC^TION
CITY OF SPRINGFEILD
BUILDING S/TFETY DIVISION
SPRTtYGFTELO
0ffice:
INSPECTION LINE:225 Fifth Street
Springfield, Oregou 97477
726-3759
726-3769
CITY-OF
4:Job Location:
Assessors MaP ll :
0vner:
Address:
Ci tY:
Z>
Tax Lot fl:a 7
Phone: *:
Zip Code:
2 *ov 7r
4>7
*-a
Phone S:
S ta te:
PreliminarY InsPection is $15
irooa- s tor"7P"II" t/rnsert . PgtT
iI"-.-iio.oo i"""nce = sz^6'2
.00 (prior to installation of insert)
it is s1s.oo . s';;-;;'i"'-"u'"t'';;; ; S'45 administrative
Va1ue of Uood St
Typ e of InsPection Requested:
Contractor:
3769 ) .I stat e that a
Inser t :
0 total
II the i
Address:2
zip Qode ' a.- c-/-7 B
StateCity:
tors Registration *:- ^r=Expires, ?-Z<-?G
Construction Contrac
By signing this Pe rmi t /aPP lication,I agree to caII for insP ection(s)as required
n format io n on this Pe rmit/aP plicat ion is correct
and t hat I lras Pro vided vith the Uood Stove SafetY in formati on for vo od burning(726-
APP lian ces and Preli minarY insP ecti on standards'I further stat e that the appl iance
Iam installing mee ts smoke em ]ss1 on s tandartJs as set bY the Oregon Depar tmen (ot
Envi ro
rovide the
nmental QuaIi tY
testing aPP
or the Fe
roval number
deral Environntctt
to the itrsPec
tal Prot
tor a
ection AgencY
i tt" time of
and I agree to
insPection 'I
P tand that if I am reques ting a Prc)'imin nspection, the vall cover ingary i
also unders
may be requ ired to be rem oved.
e
ure ====
==== ===== ====== ======= ===--==FOR OTTI
REQUIRED INSPECTION(S) :uooDsrovE t$@ttNSERr
Date of APPIication:
=--======-============================--=========ECU USE
PRELIMINARYq-
?a
Total Amount Collected:
Receipt \z
"22*,1
Job ll:
Issued BY:
'Checked for Deliquencies: /(.llrccked for llistorical S tus:
f