HomeMy WebLinkAboutPermit Mechanical 1995-04-12/)ez-
UOOD STC}VE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY D]VISION
225 Pifth Street
Springfield, Oregon 97477
SPRINGFIELD
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INSPECTION LINE:
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7 26-31 59
726-31 69
CITY OF SPR'A'GFIELD, OR
Job Location:
Assessors MaP lt:
Ovner:
Address:
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Tax Lot #:/a>
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State:
Phone: *:
Zip Code:
Preliminary Inspection is $15'00 (orior to insta
uood Stove/pellei7ini"tt Permit i;'S15'00 + $'75
i""-.-SfO.00 issuanC€ = 526'20 tota]
llation of insert)-ti"tu surcharge + $'45 administrative
Ci ty:cV
Value of Vood Stove/PelLet Stove/Insert:
Type of InsPection Requested:
Contractor:
Address:
Ci ty:
Construction Contractors Registration #:?ZaZ- Expires, 7{^2*
Bysigningthispermit/app.l,ication,Iagre-etocallforinspection(s)aSrequired
(726_3769). , "a""",""
arr.i'.ir--,te infor*-ation on this permit/application is correct
and that I vas provided vith ti," Vood Stove S"f.i, informatibn for vood burning
appliances and pr'Ji*i.,.ry in"p".ij";-siandards' r further state that the appliance
r am installing meets smoke ".i;;j;; siandards " i"i by the oregon Department of
Environmental Quality or tf'" E"a"ta1 Environmental ProteCtion Agency and I agree to
provide the ,""ii^ng''"plrovar nri[ui- to the inspector at the time of inspection' I
also understand th;t if r am ,"q"""airg l-pi"ri*-rn.iy -inspection, the val1 covering
*rV U" required to be removed'
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Date
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REQUIRED INSPECTI0N(S): 1JOODSTOVF,#fffim)INSERT /pRELIMINARY
Date of APPIication:Job #:
Total Amount Collected:
Receipt +z /A??=t
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Issued BY:
Checked for Deliquencies:
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Checked for Historical tatus:
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state,
-i ^ ZiP code: