HomeMy WebLinkAboutPermit Mechanical 1992-10-02CITY OF OFEGO'V
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I./OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth StreetSpringfield, Oregon 97477
J.
0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Map *t
Ovner:
Address:
Ci ty:State:
Value of lJood Stove/PelIet Stove/Insert :(please circle appropriate applianc e)
l.loo o et nsert
Type of Inspection Requested:
Con t rac tor:
Tax Lot *:
Phone *:-: 1FTZ_
zipt A? ? >9?
s_$15.00 (prior to installation of insert)Permit is $15.00 + s10.00 rssuance + sl.25 st.te sureharge.
limin Ins cti on
Address:Phone *:
Ci ty:State:zi p:
Construction Contractors Registration *:.Expires:
By signing this permit/a pplication, I agree to caII for an ins pection(s) as required(726-3769). I state tha t all information on this application/permit is correct andthat I vas provided vith the l{ood Stove Safety inf ormation for vood burn ingappliances and prelimina ry inspection standards.I further state that t he appliancef am installing meets snoke emission standards as set by the 0regon Dep artment ofEnvironmental Quality or the Federal Environmental Protection Agency and I agree toprovide the test ing approval number to the ins pe ctor at the time of inspection. Ia1unders tand that if I am requesti ng a preli minary inspection, the vall coveringrequiredbe removed.
gnature Date
FOR OPFICE USE
REQUTRED rNsPEcrroN(s) : wooDsrovE /IELLET/TNSERT PRELIHINARY -Y
Date of Application: /d- Z -?z-Job *:
TotaI Amount Collected:a4r
Receipt *, d:V83 rssued By:
Checked for Delinquencies:for Historical Status: