HomeMy WebLinkAboutPermit Mechanical 1995-01-25b
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, oregon 97477
Job Location:oSe
s;PRINGFIELE,
0f f ice:
INSPECTION LINE:
7 26-37 59
7 26-31 69
,4
Tax Lot #:
Assessor-c l4aP *:
ovne. G/o n,
Address:o
u Zt tt t\
a Phone: *:
Zip Code:
726-7 7//
,l State:Or ?7,/72
Ci ty:
Prelimiuary Inspection is $15'00 (pr
u;;a-s;;.,"7P"ttltzrnsert Permit is $
i""-.-Sro.00 issuanC€ = 526'20 total
ior to installation of insert)
15.00 * $.75 tt.i" surcharge * $'45 administrative
Va1ue of Uood Stove/PeLlet Stove/Insert:
Type of InsPection Requested:tr a a
I
L
Contractor:
orovide the testi
also understand t
Phone #:Address:
Ci tY:State;
Construction Con ractors Registration *:Expires:
By signing this permit/aPP Iication, I ag ree to call for insP ection(s) as required
(726-3769).I state that a tI the informa tion on this Permit/aPP lication is correct
and that I vas Prov ided vi rh the Vood S tove SafetY information for vood burning
app Iiances and Prelimi nary insPe ction stand ards. I further state that the aPPliance
Iam installing meets smoke emi ssion standa rds as set bY the 0 regon DePartmenf of
Environmental QuaIitY or the Federal EnvironnenI af Protection AgencY and I agree to
val,number to the insPe ctor at the time of i ction. I
may be r uired to be removed.
ure
nspe
va11requesting a Prelimin ary insPection, the covering
- 2{-7t
Date
(
Issued BY:
Checked for Historical Statusi--
ng appro
hat if I am
== = = == = = = = = = = = = = = = = = = = = === == = = == = = = === = = == === == =-- = == =r POR OFTTCE USB
REQUIRED INSPECTION(S) :V0oDSTOVE / PELLEL / INSERT-- PRELIMINARY
Date of APP1ication:Job #:lL.
Total Amount Coflected:
Receipt #:
€,I
t
Checked for Deliquencies:
CITY
Zip Code: '
I
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