HomeMy WebLinkAboutPermit Mechanical 1991-10-16a
TIOOD STOVE/INSERT INSPECTI.
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
,PPLICATION
225 Fifth Street
Springfield, Oregon 97477
Job Location:
Assess
0vner:
Address:
Ci ty:State:
Stove/tove/Inser $t:
ease circle ap ate appli ance
Type of Inspection Requested
Contractor:
Address:
Ci ty:State:
Construction ctors Registration *:
gnature
POR OFFICE USE
By signing this permit/apprication, r agree to carr for an inspection(s) as required(726-3769)' r state thai'arr informati6n on ihi, "ppri""iion7["rrit is correct andthat r vas provided vith the uood Stov" i"i"ty- inrormation io.'rood burningappriances and preriminary inspection standaris. r further state that the appriancer am instarring meets smoice emission standards-;. ;";-;y"ii""oi"gon Department ofEnvironmentar Quality or the Federal Environmentat protection Agency and r agree toprovide the testing approvar number to th;-i;.f".to, at the time of inspection. rarso understand ttrit ii r am-requesting a preiiminary insf;";i;n, the varr coveringmay be required to be removed.
0ffice:
INSPECTION LINE:
726-3759
726-3769
Tax Lot fl:
, Phone *:
Value of
(pr
zip:
ip:
-Preliminary.fnspection is $15.00 (prior toIlood Stove,/Pellet/fnsert permit is- 915.00 +
installation of insert)
$10.00 Issuance + 91.25 state surcharge.
c
Phone #:
res:
e
LLETREQUTRED TNSPECTTON(S) :
Date of App}ication:
Total Amount Collected:
Receipt *:g
PRELIHINARYq\
Checked for Delinquencies:
Job fi:
Ch.ecked for Historical Status:
I Issued By
Cr iqrnaf d€t$ffi%tn aoP lc\
@s
*:
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