HomeMy WebLinkAboutPermit Mechanical 1993-08-27.@ 4eftii,t
C,ITY OF OFEGO'V
IIOOD STOVE/INSERT INSPECTION APPLICATIONCITY OF SPRINGFIELD
BUILDTNG SAFETY DIVISION
225 rifth StreetSpringfield, Oregon 91477
Ci ty:State:
Type of Inspection Requested:
Con t rac tor:
Address:
Ci ty:
REQUTRED rNspEcrroN(s) : @@ELLET
Date of Application: .**?^47
Total Amount CoIIected:
Receip t *: /B2
-T' zipz a276/
Phone #:- - -E uC>G
zip:
Phone #:
PRELIMTNARY
6
S.ORI]I.GFTELC,
0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:e
Assessors Hap # t /:
=
.z ?-< Z rax Lot *:
Ovner:I
Address:
Preriminary rnspection is $15.00 (prior to installation of insert)rJood Stove/pe,let/rnsert permit i;'sri.oo-*-Irtiloo rssu.n""-.-s.25 srate surcharge.
State:
Construction Contractors Registration *:lres 3
By signing this permit/application, I agree to call for an ins pection(s) as required(726-3769). r s tate that aII informat ion on this application/permit is correct andthat I vas provi ded vith the llood St ove Safety infornation for vood burningappliances and preliminary inspecti on standards. I further sta te that the appliancef am installing meets smoke emissi on standards as set by the Oregon Department ofEnvi ronmen taI Quality or the Fed eral Environmental pro tection Agency and I agree toprovide the t esting approval numLber to the inspector a t the time of inspectlon. Ialso underst and that if f am re questing a preliminary inspection, t he vaII coveringmayrequired to be removed.
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OFFICE USE
Job *:
Checked for Delinquencies:
Issued By:
for Historical Status:
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
gUTLOTNC SAFETY DIVISION
225 Fifth Street
ipiingtield, oregon 97 477
5-E.rgrtELv
0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors MaP *:-o 4 *4;fr
Ovner:
Address:
Ci ty:
Tax Lot *:
Phone *:
Value of llood Stove/Pellet Stove/
(Please circle aPProPriate a
zip:<2/>^
er
State I
Insert:
ppliance
Preliminary Inspection is $15'00 (prlor^to
vooa-s.o""Tp.ttlt/Insert Permit is $15'00
Type of InsPection Requested:
tallation of insert)
* $10.00 Issuance + $.?5 state surcharge'
-ICITYOF
By signing this permit/application, I agree to-call for an inspection(s) as required'
(726-37Gg). r =iate thai'aff inioit.ti6n on thi; application/permit is correct and
that I vas provided vith the VooJ-iior" Safety infoimation for vood burning
appliances and preliminary inspection standaris. r further state that the appliance
I am installing meets "roi." emisslon standards as set by the Oregon Department of
Environmentar ouaiiiv ot the Federal Environmental Protection Agency.and r agree to
provide the testing approval nurber to the inspector at the time of inspection' I
also understand that if t am reqi""ti.S-a pretiminary inspection, the vaII covering
Contractor:
Address:Phone *:7/=^saq
Ci ty:statez Z%- ziPt-?7 ?/
construction contractors Registration *t Heia Expires:
be required to be removed.
P*r -7s
OTFICE USE
REQUIRED INSPECTION(S) :PELLET
Date of Application:Job
Total Amount CoIIected:/r*
re
Receipt ff:
U
PRELIMINARY
Checked for Delinquencies :
tDru;;8y:
Checked for |lis toriul ,fhfus:
@
:7?^Fr'
Date