HomeMy WebLinkAboutPermit Mechanical 1996-09-25,aC'TY OF
UOOD ST(IVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING S/tFET)' DIVISI0N
225 Fifth Street
Springfield, Oregotr 97477
SPATNGFIEL()
0ffice:
INSPECTION LINE:
7 26-3759
726-3769
tuJob Location:
.. Assessors Map ll :/ 7n3 z-./z
0vner:
Addressl. 2?1ut 11^*'-
Ci ty:S ta te:\a Zip Code:8l+zz
Value of Uood Stove/Pellet stove/rns ertr( iLSSw
Preliminary Inspection is 515.00 (prior to installation of insert) '
Uood StovuTpettitUlnsert permit is-S15.00 + $.75 state surcharge + $.45 administrative
fee * 510.00 issuance = 526.20 total
Type of Inspection Requested:),t---I t*t -t bl Zv*azT -fc-boTt^- ll NE" AA2
Phone li:Address:
Ci tv: Sta te:Zio Code
Construction Contractors Registration $:Exoires:
By signing this permit/application, f agree to call for inspection(s) as required
<iZO-ilOgl. I state thaf-aII the information on this permit/applic,ation is correct
and that I vas provided vith the Uood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
f'am installing meets srtk. emission standartJs as set by the Oregon Departmenf af
Environmental Quality or the Federal Environnrctttal Protection Agency_ and I agree to
proviie tlre testing approval number to the itrsltector a.t the time of inspection' I
also understand ttrit ii I am requesting a prcJ.iminary inspection, the vaII covering
required to be removed.
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gna ture te
==== == = === == = = ======== = === =================== = = = ===== ============================ ===== =r FOR OFFICD USE
REQUIRED INSPECTION(S) : vo0DST0V PRDLIMINARY
Date of Application:JoLr ll:
Total Amount Collected:
Receipt ll: 2 975 Issued BY:
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PDLLET/
-Checked for Deliquencies:Chccked for Itistorical Status:
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