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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: u // ^2