HomeMy WebLinkAboutPermit Mechanical 1993-08-05VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPFT]{GFIELEl
0ffice:
INSPECTION LINE:
726-37s9
726-3769
CITY OF OFEGO'V
Job Location: L/tJF Yat1
Assessors Map *:)10<3 4 Tax Lot #: OSSOa
Ovner:
Addressr U(? Ll t)
State: Op
7./6- z3G(
Zip: q'7111-7Ci ty:
Value of Vood Stove
(please circle
Phone *:
er t:
appropr a e appli ance)
PreI
llood
1 t ion is $15.00 (prior to installation of insert)nsert Permit is $15.00 + $10.00 Issuance + $.15 state surcharge.
Type of Inspection Requested:DB. r t,,*
Contractor: L
Address:r Phone *:Gv< -9t3
Ci ty:€dG State:zip: q'lLIOL
Construction Contractors Registration #:57 ZCO Expires:
By signing this permit/application, I agree to caII for an ins pection(s) as required(72 6-3769). I state that aII information on this a pplication/permit is correct andthat I vas provided vith the llood Stove Safe ty information for vood burningappliances and preliminary inspection standa rds. I further state that the applianceI am installing meets smoke emission stand ards as set by the Oregon Department ofEnvironmental Quality or the Federal Envi ronmental Protection Agency and I agree toprovide the testing approval number to th e inspector at the time of inspection. Ialso understand that if I am ting a prelimi nary inspection, the vall covering
may be required to be removed.
Rqturete
FOR OFFICE USE
4qsoeIIet St
tove/Pelle
REQUIRED INSPECTION( S) :
Date of Application: 8
Total Amount Collected:
Receipt S:Ct e
INSERT PRELTI.|TNARY )a
Job *:
1=
Issued By:
XChecked for Delinquencies:Checked for Historical Status I y
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