HomeMy WebLinkAboutPermit Mechanical 1992-06-24CITY OF SPR OREGO'V
SPlrT'{GF!ELD
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INSPECTION LINE:
%IJOOD STOVE/INSERT INSPECTION APPTICATION
CITY OF SPRINGFIELD
BUILDING SAFBTY DIVISION
225 Ptfth street
Springfield, 0regon 97 477
726-3759
726-3769
8 6fiJob Location:
Assessors Map #:t10)I41-=4 Tax Lot *:
Owner:
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Address:4/AJ-^--
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Date of Applicatlon:
Total Amount Collected , ff qO ,76
Receipt *:5z
PRBLIMINARY
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Phone #:
(L Zipt 4t+"77State:
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Preliminary Inspection is $-15.00 (prior to installation of insert)
Wood StoveTpettlt/Insert permit is $15.00 + $ ,75 state surcharge + $lQ.00 Issuance.
Type of Inspection Requested:
Value of llood Stove/Pellet Stove
(please circle approPriate
9,
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Cont rac tor:It
Address:Phone #:
Ci ty:S tate:ts*Zip:q74 3/
Construetion Contractors Registration S:alq s4 Expires:
By sign ing this permit/application' I agree to caII for an inspection(s) as requlred
(726-3769>.I state that aII lnformation on this app Ilcatlon/permlt is correct and
that I was p rovlded with the llood Stove Safety informa tlon for wood burnlng
appliances and pre Ilmlnary inspection standards. I fu rther state that the aPPllance
I am installing mee ts smoke emission standards as set by the 0regon Department of
Environmental Quality or the Federal Environmental Protectlon Agency and I agree to
provide the testlng approval number to the inspector a
prellminary
t the time of insPection. I
also understand that if I am requesting a inspection t the val} coverl ng
requ be
/
gnature te
FOR OFFICE USE
Issued By:
Checked for Delinquencies:Checked for Historical Statuss
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