HomeMy WebLinkAboutPermit Mechanical 1994-10-17CITY OF OREGON
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUTLDING SAFETY DIVISION
225 Pif.th Street
ipringfiefd, Oregon 97477
Job Loc ation z ii#Y4 $r
Assessors MaP #:
ISPF'A,GF'ELC'
0f f ice:
INSPECTION LINE:
0 E Gorrt
Tax Lot *:
726-3759
726-3769
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{%*Ovner:Lucv J t (76rvn (r
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*"(.t*Phone: #:n,{ G ob( Ll
Address:
Ci ty:-s State, (t,Zip Code 7'l')zcl
Value of Vood Stove@e1let-: Stove/Insert:{(h oa/
Preliminarylnspectionis$15.00(priortoinstallationofinsert)
vood Stov e/Pe;ler/rnsert Permit t:';i;:00"."d:;;-"i"t" surcharge + $'45 administrative
i""-.-Sto.00 issuanC€ = 526'20 total
Type of InsPection Requested:?t.(.1et -f: 11)d.!-L,.uL + [-et-/i L
I
(.^b't/laContractor:
Address:o.
Ci ty:L State:
Construction Contractors Registration #, 46fl{
gnatur /0
Bysigningthispermit/app.l.ication,lagre.etocallforinspection(s)asrequired
(726-3769). , ,,"r',""-,iJi'"if tf,"
'.,formition
on this permit/application is correct
and that I vas provided vith ii," Vood Stove
-;"i"ty informatibn for vood burning
appliances and ptlli*lr,.ry irr"p""li";-siandards'--t further state that the appliance
I am installing meets smoke "*i";1;; tttna"a" "t ""i Uv the 0regon Department of
Environmental Quality or tf'" f"a"tiI gnvironmentaf ProteCtion Agency an<i I agree to
orovide the testing approval "rii"i- to the in-"p""tot at the time of inspection' I
also understand thJt if I am t"O"l"tiig '
-pitf i';i;;y inspection' the vaII covering
;.v-u" required to be removed'
Phone #:
Zip Code
Expi res :
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to lrt
Total Amoun t coll-ec ed:
ReceiPt *:
ate
USE
PRELIMlNARY
Job *:
Issued BY:
VOODSTOVEREOUIRED INSP
Date of APP}ication D
Checked for Deliquencies:Checked for Historical Status:
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