HomeMy WebLinkAboutPermit Mechanical 1996-10-01C'TY OF I
SPFlINGFIELO
Office:
INSPECTION LINE:
UOOD ST('VE/INSERT INSPECTION APPLICATIOI.I
CITY OF SPRINGFEILD
BUILDING S/rFETl' DIVISI0N
225 Fif th Str-eet
Springfield, Oregon 97477
Job Location 5t-
Assessors Hap li:
0vner:i&
6+
Tax Lot {l:()
Plrone , *r 7L/b ^ L/("
O?Zip Code:4zn
p.tltl
%
t26-3759
726-37 69
Addre
Ci ty:
ss:
n S ta te:
Value of Uood Pellet Stove nser t :
Prelirninary Inspection is S15.00 (prior to installation of insert)
Uood Stove/Pellet/Insert Permit is S15.00 + $.75 state surcharge + $.45 administrative
fee + 510.00 issuance = 526.20 total
Type of Inspection Reques ted:
Con t rac tor:
Address:P 2
Date of Application:
Total Amount Collected:
Receipt ll:93%)
v /0-/-%
Phone li:
Ci ty:State Zip Qode:
Construction tt-actors Registration $qbfr{
By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that al} the information on this permit/application is correct
and that I vas provided vith the llood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Departmenf crf
Environmental Quality or the Federal Environnrcntal Protection Agency and I agree to
proviie tlre testing approval number to the iusgrector at the time of inspection. I
also'under and that if I am requesting a prc).iminary inspection, the va1I covering
may be re removed.
c?
lgna ure /h*
. FOR OTFICU USE
REQUIRED INSPECTION(S): VOODSTOVE @qu6 tc'/-qa t73.o
INSDRT PRELTl,TNARY
Job {l:
fssued By:
-Checked for Deliquencies :Ulrccked f or Ilistorical- Status:n1q-
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Expi res : _
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