HomeMy WebLinkAboutPermit Mechanical 1994-09-09CITY OF SPR OFEGO'V
IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 ?ifth Street
Springfield, 0regon 97477
SPFt}IGFIELD
0f f ice:
INSPECTION L]NE:
7 26-37 59
726-31 59
*-J
Job Location:r\ s'l.
Assessors MaP *:'o ^3 2./
Ovner , J ncK C oTr(-C^*r(,
Address:rte t N)
State, C R.
Tax Lot *4 26a*
Phone: #:
Zip Code:
TeLa - SkiU
4-\{-t'1
Ci, ty:S r (
Value of Vood Stove/Pelfet Stove/Insert:*qoo=
Preliminary Inspection is $15'OO (prior-!o ilsllllation of insert)
uood Stove/pe11ei7i"r"tt Permit i;'$i;:06-* $'zs-siaie sureharge + $'45 administrative
i""-.-SrO.00 issuanc€ = $26'20 total
Type of InsPection Requested:
nn -C
Y
Contractor:o
E-Address: J Phone *:-1r.lb alt
Ci ty:cJ State:R Zip Code;?tql R
Construction Contractors Registration *:A(c 7 Ll3 Expires:G
By signing this P ermi t/app lication, I agree to caII for inspection(s) as required
(7 26-3769). I st a te that al-1 the information on this Permit/aPP lication is correct
and that I vas P rovided vit h the Vood Stove SafetY information for vood burning
app Iiances and Pre liminarY insPe ction standards.I further state that the aPPl Lance
Iam installing me ets smoke emi ssion standards as set bY the Oregon DePartmen tof
Environmental- Quali ty or the Fed eral Environmen tal- Protection AgencY and I agree to
rovide the testing aP num ber to the insPe ctor at the time of inspection. I
aI so understand that i requesting a Prelimi nary insPection, the vall covering
may be required to be r emoved.
4 E
te
S re
=========================--=============================================================FOR OFFICE USE
REQUIRED INSPECTION( S) :@ry ELLET/INSERT ./- PRELTMTNARY
Date of APP1i.cation:Job *:
2Z .24
Issued BY:
,proval
flam
Total Amount Collected:
Receipt +, / Y663
Checked for Deliquencies:Checked for Historical tatus:
llr n). sI
/7
3.a.nr-\r-A s,\ .