HomeMy WebLinkAboutPermit Mechanical 1993-08-24SP-alX66r=aO
ON APPLICATION
225 .Fif th StreetsPringfield, Oregon 97417 0ffice:
TNSPECTION LINE:
726-3759
726-3769
Job Location:AJ,ts4q
Assessors M.p *,3z
0vner:lil t,
Address /gZS d-
Tax tot *:
Phone #:
Ci ty:State:ZipzValue of llood Stove/pellet Stov(please clrcle "pprop.i"ii
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Preriminary rnsoection is $15.00. (prior to instarration of insert)Iiood stove/perllt/rnsert-pl.iil"ii- Sij.od-.-Iio.oo rssuance + $.1g
Type of Inspection Requested:
state surcharge.
Con t rac tor:
Address r S(Y 2 Phone *:
Ci ty:t State:Zipz
Construction Contractors Registration *, Zf_-#3 Expires:
By signing this permit/application, I agree to caII for an ins pection(s) as required(726-3769). r s tate that all informat ion on this application/permit is correct andthat I vas provi ded with the llood St ove Safety information for vood burningappliances and preliminary inspecti on standards. I further s tate that the applianceI am installi ng meets smoke emissi on standards as set by the Oregon Department ofEnvi ronmen taI Quality or the Feder aI Environmental pro tection Agency and I agree toprovide the testing approval numbe r to the inspector a t the time of inspection. Ialsounderstand that if requesting a preliminary inspection, the vaII coveringmay be ired t o
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FOR OFFICE USE
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REQUIRED INSPECTION(S): V0ODSTOVE/PE
Date of Applicationz 2 - Z-y' - ?3 .. Job *:
Total Amount Collected:?c
\Receipt S:ssued By:
PRELTHINARY
Checked for Delinquencies z t---Checked f or Historical Status:
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