HomeMy WebLinkAboutPermit Mechanical 1992-11-09SPFTXGFTELD
JrIIOOD STOVEIINSERT INSPECTI
CITY OF SPRINGTTTLD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
ON APPLICATION
-772-u-
lCe:
NE:
726-37s9
726-3769
Job Location:?<
Assessors Map *: /.7a3-z {-V/
0vner:
Address
Ci ty:State:
Value o l,lood t Stove/Insert:2-3&4(please circl e appropr iate appliance) f
1
U ov
Type of Inspeetion Requested:
Con t rac tor:
Address:
Ci ty:
Cons truct ion
may be required to be removed'
ture
Receipt t:a77z-Issued BY:
Tax Lot #: 4E?5a-c5
0,M
Phone #:5q7477_zip:
?'-
Phone *:
Staterft Zipz
ctors Registration *' 46fA{ Expires z ,/?'zg-a 3
(prior to installation of insert
1S 15.00 + $10.00 Issuance +state surcharge.
.rjt
?*
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769), t siate thai'a1I informati6n on this application/permit is correct and
that I vas provided vith the Uood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets "rot" emission standards as set by the Qregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testins .pproral number to the inspector at the time of inspection' I
also understand that if t a, ,eql""ai.g-a preliminary inspection, the va1l covering
FOR OFFICE USE
REQUIRED INSPECTI0N(S) : I'I0ODSTOVE PRELIMINARY
Date of APP1ication://-22_Job * z ?zrt5<4
TotaI Amount Collected:
Date
1s.00
et nse
Checked for Delinquencies:Che for Historical Status:
-
UF,l1)-,t