HomeMy WebLinkAboutPermit Mechanical 1994-10-25CITY OF SPRINGFIELD, OREGOA'
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, oregon 97477
SPRIII.GFIELO
0ffice:
INSPECTION LINE:
726-3759
726-3769
Lt5z S 4t'^&Job Location
Tax Lot #:0t& 6b
Assessors MaP #:t:a12574
Ovner:
L {-l^Phone: *:7Zb ?bfr
Address:
Ci ty:State:0Y-_Zip Code ,q 7 L{77
5D
Value of Vood Stove/Pe1Iet Stove/Insert:
Type of InsPection Requested:
Contractor:IUJ]^.4-l
Address:
r.i rrr. State:Zip Code:
ate
gna ture
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OFFICE USE
Construction Contractors Registration #: Expires:
Bysigningthispermit/appljcation,Iagre.etocallforinspection(s)aSrequired
(126_3769). r "tr"i""ir.,"i'"rr- t[" intorm'ation on this permit/application is correct
and that I vas provided vith in" Vood Stove ;"i"t information for vood burning
appliances and pr'"liri;;.y inspe",l";-siandards' t further state thal the appliance
r am installing meets smoke "*i;;i;; Jandards "= ;;i - uy tr'e 0regon Department of
Environmentaf Quality or tne feaeiil gnvironmental Protection Agency and I agree to
orovide the testing approval nui["i-'o the inspector at the time of inspection' I
also understand thit if I.r t"oul"ai"g.-pt"tili'";y inspection' the val' eovering
,uV Uu required to be rernoved'
t*
Preliminary Inspection is $15'00 (prior to ins
;;;a-it;;"7p"uli7ini"'t Permit is $15'00 + $'
i""-.-Sio.00 issuance = 526'20 total
tallation of insert)
is-"i.t" surcharge * $'45 administrative
===== = = = = === = =========--===================FOR
REQUIRED INSPECTION( S) :6;r t;;;; r entt*r r tN sERr
Date of APPIication:
Totaf Amount ColLected
ReceiPt *:'Lt
Phone *:
t/" PRELIMINARY
Job #:7qt r"
Issued BY:
Checked for Deliquencies:
Lb zo
Checked for Historical Status:
t