HomeMy WebLinkAboutPermit Mechanical 1994-07-26VOOD STOVE/TNSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, Oregon 97477
SPRIltlGFTELI,
0ffice:
INSPECTION LINE:
726-3159
7 26-37 69
CITY OF OREGO'V
,?2 z.D t
Job Location
Assessors MaP *:Tax Lot #:4
AIJ f - Uarbfi,*
Address 4 45 fr -/3rJ Sf0vner
Ci ty
7f/ q 7)f
J
Phone: *:
Zip Code:
6
?tState:e
ve7Pe1let Stove/Insert :4XZ2 G
Value of Vood Sto
Type of InsPection Requested:
Preliminary Inspection is $15'00 (pr
;;;a-'i,;;"TP"trltzrnsert Permit is $
i;;-.-S10.00 issuance = 526.20 total
ior to instaflation of insert)
ii.oo + $.zs staie surcharge + $'45 administrative
contractor:
Phone *:
=
*72,/a
Address:
Ci ty:State:Zip corie : ?- /a z-
Construction Contractors Registration #/4- < ExPires: /t2^Za-47
Bysigningthispermit/appI-i.cation,Iagre.etoeallforinspection(s)asrequired(726_3769). , .,""","" aiJi"Jr--irr" i.,for*""tion on this permit/application is correct
and that I vas provided vith the Vood Stove iat"ty information for vood burning
appliances and prllirinary in"pe"tl";-siandards.--t further state that the appliance
r am installing meets smoke "*i;;l;; siandards.. ""t by the 0regon Department of
Environmental Quality or tn" r"alial Environmental Protection Agency and I agree to
orovide the testing approval .rrrUlt- to the inspe"tot at the time of inspection' I
also understand thtt if r am."qrl"airg.-pr"ri*-rn"iy inspection, the varl covering
,ay U" required to be removed'
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egnature
=============================================================--====================-_====FOR OFFICE USE
REQUIRED INSPECTION( S) :
(-"-- PRELTMTNARY
Date of APPIication:7 q Job #:4
Total Amount Collected' /5*
Receipt n, t/Ofu Issued BY:
Checked for Eistori caI S
/INSER
Checked for Deliquencies:atus:
9
31 -//
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVIS]ON
225 Yifth Street
Springfield, Oregon 97477
SPFINGFTELE,
0ffice:
INSPECTION LINE:
t 26-31 59
726-3769
CITY OF SPB"UGFIELD, OREGO'V
-L{Job Location:
Assessors MaP *:
Ovner:
Address:Phone: *:
Zip Code:
72 -'
State:tu
Va1ue of Vood Stove/Pell-et StoveTlnsert:,b
preliminary Inspection is $15.00 (prior to installation of insert)
vood Stove/Pe11et/rnsert Permit i;'ai;:Od-*-$'Zs-siate surcharge + $'45 administrative
i;; .r $10.00 issuance = 526'20 total
Type of rnspection Reques rca: /Ed4 nsSb<7
Ci ty:
d-o
Contractor:
Phone *:Z
Address:
City; f State 44 . ZiP Code:0.2
Construction Contractors Registration *' /- f,o-C Expires:-z
By signing this Perrni t/ app lication, I agree to call for inspection(s) as required
5
(726-3769). I state t hat all the information on this permit/aPP lication is correct
and that I vas Provide d vith the Vood Stove Safety information for vood burning
appliances and Prelimina ry inspec tion standards I further state that the aPPliance
I- am installing meets s moke emis sion standards as set bY the 0regon Department of
Environmental QualitY or the Federal Environmen tal Protection AgeneY and I agree to
inspeetion. I
prov ide the testing aPProv aI nunber to the insPe ctor at the time of
also understand that if I am requesting a Prelimi nary insPection, the vaIl covering
may be required to be removed.
gnature e
==_-=======__================================--==============================FOR OFFICE USE
=============
REQUIRED INSPECTION(S) :PRELIMINARY
Date of APP1ication:2 Job #:
Total Amount Collected:2D
Receipt #:Issued BY:
Checked for Deliquencies:/ /4(-^
20
Checked for Historical Status:
,,- 3 7G / y' TaxLot +: t:7brfl
3
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