HomeMy WebLinkAboutPermit Mechanical 1999-11-02WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMLINITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97 477
SPRIIYGFIELE'
Office: 726-3759
INSPECTION LINE: 7 26-37 69
CITY OF OBEGO'V
4Job Location
Assessors Map#: / 7072 7 c/ ' Tax Lot#:a3-? /
4(>oD z-EOwner:o +
Address:/J 30fr 7//- {/st
(4DCity:State:?t u r7
Value (please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + Lo5 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
Type of Inspection Requested
Contractor:
Address Phone#:
state: Zip:_
Construction Confr actors c
By signing this perrnit/application, I agree to call for an inspection(s) as required (726-3769). I state that
all information on this application/permit is correct and that I was provided with the Wood Stove Safety
information for wood buming appliances and preliminary inspection standards. I further state that the
appliance'i am installing meets smoke emission standards as set by the Oregon Deparfinent of
Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing
approval qumber to the inspector at the time of inspection. I also understand that if I am requesting a
preliminary inspection, the wall covering may be required to be removed.g"4b
Date
FOROFFICE USE
REQUIRED PRELIMINARY
Date of Aoolication: //- 2 -4q Job #:
Total AmountCollected: 26. 22 Receipt *: 7@2? Issued By:
Checked for Delinquencies:_ Checked for Historical Status:
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