HomeMy WebLinkAboutPermit Mechanical 1993-11-02I.IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPRIi.GFTELO
0ffice:
INSPECTION LINE:
h
726-3759
726-37 69
OREGO'VCITY OF
Job Location:5+h
Assessors ilap *, /?-O7 -7'- -Z/ Tax Lot *z / 02#
0vner:
Addre
Ci ty:
ss: lLl["6Lh Phone #: t1t\ \ .32 Otov
zip:ryr q'l-l
Value o ellet Stove/Insert: .y QS'o"(please circl e appropriate appliance)
Preriminary rnspection is S15.oo (prior to instarration of insert)vood Stove/Pe}let/Insert Permit is $15.00 + $1O.OO Issuance + 5.1, state surcharge.
Type of Inspection Requested:rsl{,*
State:
Contractor:i
Addre
Ci ty:
SS:5 Mrai,.:'t Phone *: It{to -bZZl
zip:q1
Construction Contractors Reg istration *r 2bl({Expires: t:2C-?/
this permit/application, I agree to call for an ins pection(s) as requiredI state that all information on this application/permit is correct andprovided vith the Uood Stove Safety information for vood burning
and preliminary inspection standards. f further sta te that the applianceling meets smoke emission standards as set by the 0r egon Department ofaI Quality or the Federal Environmental protection Agency and I agree totesting approval number to the inspector at the ti me of inspection. Itthat if I am requesting a preliminary inspecti oDr the val1 coveringtober
State: M-
By signing
(726-3769).
that I vas
applianees
f am instal
Envi ronmen t
provide the
also unders
may be requ
gnatur Ir.L
Date
OFFICE USE
REQUIRED INSPECTI0N(S) : VOODSTOVE /PELLET /INSERT
Date of Applicat ionz //^ 2-A7
Total Amount Collected: 25_ ?S'
Issued By:
PRELIMIN}I,Y
Job #:/
Checked for Historical Status:Checked for Delinquencies:
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Receipt *: /IZZ€Z-