HomeMy WebLinkAboutPermit Mechanical 1995-04-05I/OOD STOVE/INSERT I
CITY OT' SPRINGTEILD
NSPECTION APPLICATION
SPRI?{GFIELD
0ffi ce :
INSPECTION LINE:
Fifth Street
ingfield, Oregon 97477
225
spr
7 26-37 59
7 26-37 69
CITY OF
Job Location:(o f
Tax Lot #: D62 O-..>
Ovner:
Phone: *:
Zip Code:
+E+ ^c{ Q
Address:
Ci ty:
Value of Vood Stov /Inser t :$l3o o
state, Q*
Preliminary Inspection is $15.00 (prior to ins-tallation of insert)
v""a-Si""""/J"lllirinr"rt Permit i;'$15.00 + 1;'75 state surcharge * $'45 administrative
fee + $10.OT-issudnC€ = 526.20 total
V,l \*.+
let St
tContractor:
Address:
Ci ty:
Date of APP1ication:
Total Amount Collected ' 24 rzo
Receipt +, /b36 (
Phone *:+)4-c4[ n I
Zip Co dez 41 f op
Job *:
Issued BY:
Checked for Historical Status:
,t-
State:
Construction Contractors Registration *: Expires:
Bysigningthispermit/app]jcation,Iagre.etocallforinspection(s)asrequired
(726-3769). f "t'rt" that ^alI tfr" inform-atioi-) on this permit/application is correct
and that I vas provided vith the vood Stove safety information for vood burning
appliances and pJJirin.ry inspecil";-siandards. r further state that the appliance
I am installing meets smoke "t,i;;l;; standa; *'ls as set by the Oregon Department of
Environmentar Quality or tn" r"a"raI Envirorrr*e.ta1 protection Agency and r agree to
orovide the tes ting approval nr*i"i- to the i']tp""tot a-t the time of inspection' I
arso understand that if r am r;;;;ting . -pr"tim-i.,a.y inspection, the va1I covering
may be required to be removed'
tgnaure
=======================================================================================I POR OIi"TCE USE
REQUIRED INSPECTI0N(S) : vo0DSTOVE/?t{f,E}t'I}JLIiJRT T.*PRELIMINARY
437
Checked for Deliquencies:
-'-'t--'_---" - _-.
BUILDING SAFETY DIV]SION
Assessors Map {l , /7O \ 3Cr I Z
Type of InsPection Requested: