HomeMy WebLinkAboutPermit Mechanical 1992-08-13sPIrllirciFr€Lt
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INSPECTION LINE:
afrIJOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Ftfth Street
Springfield, 0regon 97477
726-3759
726-3769
CITY OF OBEGO'U
Job Location:
Assessors Map #:.2,
Ovner:
Address:
Ci ty:
value of<ff;a-SiotE/Perret st
State:2,4.
Tax Lot *: 4AE?a>
Phone *, -l -*2 /-
zip:4?-T*
7ft,a_+./<aa -'-_
hr/*a4.r-a' n-,hsEzz-
(please ciicle appropriate appliance)=- -
Preliminary Inspeetion is $15.00 (prior to installatlon of insert)
IIood Stove/Pelllt/Insert Permit is $15.00 + S.75 state surcharge + $10.00 Issuance.
Type of Inspection Requested:Ly'*irr/ove-
Contractor:
Address: phone #:
Cityt State:zip:
Construction Contractors Registration #:-Expires:
By signing thls permit/application, I agree to call for an inspection(s) as required
<iZO-5lOgt. I state ttai-alI information on this appllcatlon/permit ls correct and
that I vas provlded with the llood Stove Safety informatlon for wood burnlng
appliances ind prelimlnary inspectlon standards. I further state that the appliance
I'am installing meets smoire emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
ilso understand thit ii I am requesting a prellminary inspectlon, the vaII coverlng
may be required to be removed.
(- /z 2n/4'- /--)- //-
Date
FOR OFFICE USE
ture
REQUIRED INSPECTION(S) :IIOOD STOVE / PELLET / TN SBRT ',/- PRBLTMTNARY
Date of Application:Job *, a2/ //?
Total Amount Collected:
2F25-/2,2,4>
Receipt *z 1k'8--'
1-
4
Issued By:
C/'-Checked for Delinquencies:Checked for Historical Status: