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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: