HomeMy WebLinkAboutPermit Mechanical 1996-10-04D aC'TY OF
SPHINGFIELO
I
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING S/tFE't)' DIVISI0N
225 Fifth Street
Springfield, Oregon 97477
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0f f ice:
INSPECTION LINE:
726-3759
726-37 69
Job Location:A
Assessors Map ll :t1 bt
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Tax Lot ll :h4&oc)
Ovner:51rn /Y)*rtT/D4 Phone: ll :7-
zip code:9lVlY
Address:L
Ci ty:5p r, n sS'.iJ----7- lr
Value of Uood Stov
Type of Inspection Requested:
o
S ta te:
e/Pe}let stove/Insert: lSeO9
Preliminary Inspection is S15.00 (prior to installation of insert)
Uood StoveTpellet/Insert Permit is S15.00 + $.75 state surcharge + $.45 adninistrative
fee + 510.00 issuance = 526.20 total
Toseu-t Pe/l<-a
Contractor:,a--V'/Tpu'
Address:Phone li:8-c>>
Ci ty:e S ta te:6r Zip Qode:
Construction tractors Reg istration *, Xr7 +3 Expires:
By signing
(726-3769).
this permi t/app Iication, f agree to call for inspection(s) as required
I state that aI I the information on this permit/application is correct
and that I vas pro vided vith the Uood Stove Safety information for vood burning
appl iances and preliminary inspection standards.I further state that the aPP Iiance
Iam installing meets smoke emission standards as set by the 0regon DePartmen (qt
Environmental Quali ty or the Federal Environnrctr tal Protection Agency and I agree to
provi-de the tes t ing approval number to the iltsl:ector at the time of insPection. I
also'understand that if I requesting a prcJ.imi nary inspection, the vall covering
be requir removed
at te
M
FOR OFI]ICU USE
REQUIRED INSPECTION(S): U STOV PE INSDRT
Date of Application:
Total Amount Collected:
Receipt fl:
PRDLIMINARY
Job l[:
Issued BY
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-Checked f or Deliquencies i
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Chccked for Ilistorical Status:
ans
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