HomeMy WebLinkAboutPermit Mechanical 1993-09-28IJOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SP'TIi.GFIELO
0ffice:
INSPECTION LINE:
726-3759
726-3769
OREGO'VCITY OF
\Job Location:
Assessors Map *:
0vner:{-
Tax Lot *:
L
Address I q? ?A) t?t]Phone *:
Ci ty:
Value of llood Stove
(please clrcle approP a e
State:O^ zipz Q)e)1
LZbqOL
iance)
Preliminary rnspection is $15.00 (prior to instalration of insert)IJood stove/Perlet/rnsert permit is 915.00 + $10.00 rssuance + $.19 state surcharge.
Type of lnspection Requested:L
Contractor:
Address: S?Phone *: Gf7 qG{
Ci ty:Fr",c.Stater Cf Zip: {*/ rcZ
Construction Contractors Registration *:{7?t n Expires:
By signing this permit/application, I agree to call for an ins pection(s) as required(726-3769). I state that all information on this application/permit is correct andthat I vas provided v ith 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 standa rds as set by the 0regon Department ofEnvironmental Quality or the Federal Bnvi 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 a preliminary inspection, the vall coveringnay be required to be removed.
zr 7tureDate
FOR OFFICE USE
REQUIRED INSPECTION( S) :INSERT PRETIMINARY
Date of Application:Job
Total Amount Collected:
Receipt fl:
I
llet Stove/I
Checked for Delinquencies:
Issued By:
Checked for Historical Statuss
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