HomeMy WebLinkAboutPermit Mechanical 1995-06-01IIOOD STOVEIINSIXI INSPECTION APPLICATION
CITY OF SPNINGFE]LD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPRTNGFIELD
0ffi ce :
INSPECTION LTNE:
7 26-37 59
7 26-37 69
ctTr OF
Job Location:
Assessors Map l|, /7e?#4 rax Lot s:
0vner:
Address:-zG+2D . Phone: *:
Ci ty:State:Zip Code:
Va1ue of llood Stove/Pellet Stove/Insert:e
Type of InsPection Requested:
Contractor:7 Phone t:Address:
State:Zip C.ode:
Preliminary Inspection is $15'00 (prior to inst
u;;a-'it;;uTp"ulilrnsert Permit is $15'00 + $'7
i;; .r S1o.oo issuance = $26'20 total
allation of insert)
i-"i.t" surcharge + $'45 administrative
Ci ty:
Cons t ruction Contractors Registration #: /A?92 Expi res :
By signing this permit/aPP Iication'I agree to caII for insPe ction(s) as required
(726-376e).I state tl'rat a II the i nformatio n on this Pe rmi t/ap pI ication is correct
and that I vas P rovided vit h the Vood Stove Safety inf ormation for vood burning
app liances and Pre IiminarY insPec tion standards'I further state that the aPP liance
Iam installing me ets smoke emis sion standards as set by the Oregon DePartmen t crf
Envi ro nmental QualitY or the Fede ral Environnrctrtal Protection AgencY and I agree to
p rovide the testing a pproval nunrb er to the insPect or at the time of inspection. - I
also understand that if I am reques ting a Prc).imina ry insPection, the vall covering
may be required to be removed.
ate
gna ure
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PRELIMINARY
REQUIRED INSPECTION(S) :
Date of APPIication:6F/4{
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-, FOR OFIICE USE
.<d6lffi pi Lr,st z rN s ERr X
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Total Amount Collected:
Receipt *, /? C€?
7a
Job *:
Issued BY:
Checked for Deliquenciess Chccked for Historical S tus:
7*-
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