HomeMy WebLinkAboutPermit Mechanical 1995-05-23CITY OF SPF,,VGFIELD,
UOOD STC}VE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Pifth Street
ipringfield, Oregon 97477
Job Location:2ffiN,U $+
Assessors MaP lt:/^/2.
0vner:
Address:255 !f,-:F
S ta te:
SPRIi|GFIELD
0ffice:
INSPECTION LINE:
e J
726-3759
726-37 69
ax Lot f:
Phone: *:
Zip Code:
1-Otcl)1
q1L(11
Ci ty:
Value of Uood Stov sert:2-,Ooo . erd
Type of InsPection Requested:
Contractor:
Address:
city: A4 ,G/C state:
Construction Contractors Registration #' tr7* Expires:,a
By signing this permit/aPP lication, I agree to call for insP ection(s) as required
(726-376e).I state that a 11 the information on this permit/aPP lication is correct
and that I vas P rovided vi th the Vood Stove Safety information for vood burning
appl iances and Pre IiminarY inspec tion standards.I further state that the aP pliance
Iam installing meets smo ke emis sion standards as set by the 0regon DePartmen (. of
Envi ro nmental QualitY or t he Federal Environnrettt al Protection AgencY and I agree to
p rovide the testing aP provalflam
number to the insPe ctor at the time of ins tion. I
llso under stand that i requesting a Prc)'imi nary insPection, the va covering
may be req uired to be removed'
&rlw t
ture
= === = = ======= ===== === ======= ===== === ==
USE
REQUIRED INSpECTI9N(S): g9ODST9VE6ffgg1-1NSIRT -ll PRELIMINARY
z-9 ,Job #:?
Date of APPIication:
Total Amount Collected:
Receipt +z /78>-
t1
Preliminary Inspection is $15'00 (pr
;;il-;t;;"7P.n!tzrnsert Permit is $
i""-.-sio.00 issua.C€ = s26'20 total
ior to installation of insert)
15.00 * S.75 "t"iu--"uicharge
* $'45 administrative
pec
1I
e
= = -- = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =I f'OR OFTICE
Issued BY:
et Stov
Checked for Deliquencies:
:24
Clrecked for Historical Status:
Phone +, 6try92f?
Zip cpde, 47?{aZ=