HomeMy WebLinkAboutPermit Mechanical 1996-01-23I
SPFTNGFIELED
0ffice:
INSPECTION LINE:
726-3759
726-3769
UOOD ST(IVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
CITY OF
Job Location: eJ//.8r,
Assessors Map li:Tax Lot *:
ovnen Jo e ^l A \-./A.\.rr>
Add ress: 2-?_ I q ,i. nu s''T Phone: *:
Zip Code:
72 6 --3 B,<8
Ci ty:State: Q,
Value of Uood Stove/Pe11et Stove/Tnsert:
Preliminary Inspection is S15.00 (prior to installation of insert)
Uood StoveTpelletZlnsert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + Si0.00 issuance = 526.20 tot
Type of Inspection Requested:
Con t rac tor:
Address:
Ci ty:
Phone #:
Zip Qode: '
Construction Contractors Registration #:Expi res i
-
By signing this permit/application, I agree to call for inspection(s) as required
Q26-i769). I state thar aII the information on this permit/application is correct
and that I vas provided vi th the l.Iood Stove Saf ety inf ormation f or vood burning
appliances and preliminary inspection standards. I further state that the appliance
I'am installing meets sm-oke emission standards as set by the 0regon Departmenf o{
Environmental Quality or the Federal Environrrcutal Protection Agency and I agree to
provi<ie the testing approvai number to the iuspector at the time of inspection. I
also understand that if I am requesting a prc).iminary inspection, the vall covering
may be required to be removed.
Y
State:
t
FOR OFFICE USE
REQUIRED INSPECTION(S): UOODST0 /INSERT
Date of Application:Job #:
Total Amount CoIlected:
Issued By:Receipt #:
PRELIHINARY
6$
N *Checked for Deliquencies:-Chccked for Historical Status:
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