HomeMy WebLinkAboutPermit Mechanical 1993-04-15OREGO'VCITY OF
IJOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location
!SPFI}IGF!ELC,
0ffice:
INSPECTION LINE:
726-3759
726-37 69
Assessors Hap #:9*z 7^37 Tax Lot *: 2Z&a
Ovner:
Address:A/r1 Phone !t. ?q1 - j ,11 I
Ci ty:Ft State: O/(
Value of Lrood Stove
(please circle
IIet St 0923-@t
pr a e appl iance)
Preliminary Ins ect is $15.00 (prior to installation of insert)
I,lood S tov Permit is $15.00 + S10.00 Issuance +
Type of Inspection Requested:
Con t rac tor :
Address:LEO
Ci ty:State:
Construction Contractors Registration *:g,{7L6d
zipz 9 t4l )
W
state surcharge.
Phone *: (oY3-Og
Zipt qTqoL
lres:
By signing this permit/application, I agree to caII for an inspection(s) as required(726-3769). I state thar aII informat ion on this application/permit is correct andthat I vas provided vith the Uood Stov e Safety information for vood burningappliances and preliminary inspection standards. I further state that the appliancef am installing meets smoke emission s tandards as set by the Oregon Department ofEnvironmental Quality or the Federal Environmental Protection Agency and I agree toprovide the testing approval number t o the inspector at the time of inspection. Ialso understand that if I am requesti ng a preliminary inspection, the vall covering
may be required to be
t9
s Da e
FOR OFFICE USE
t
et/Inser
REQUIRED INSPECTION(S): V00
Date of Application:
Total Amount Collected:
Receipt *: 8f*
X PRELIMINARY -Y
Job *:7
Checked for Delinquencies:
Issued By:
ch for Historical Status:
G{
ttlq<t-