HomeMy WebLinkAboutPermit Mechanical 1995-09-13CITY OF
UOOD STCIVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILD]NG SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SPRINGFIELD
0ffice:
INSPECTION LINE:
7 26-37 59
726-37 69
Job Location:2-77* N. z/{sV
Assessors Map li:
0vner:
Address:
Tax Lot f:
Phone: #: 72A - O/Oa
Ci ty:<zn S ta te:(y Zip code, ? %- 7
Value of Pellet Stove ,h
Preliminary Inspection is S15.00 (prior to installation of insert)
Uood Stove/Pellet/Insert Permit is S15.00 + $.75 state surcharge + $.45 administrative
fee + 510.00 issuance = 526.20 total
Type of Inspection Requested:
Con trac tor:
Address:. ? Z/ 5-n Phone #:
Ci ty:State, AtQ Zip Cpde, 7-i ', '
Construction Contractors Registration +, /O3593 Expires:/ 2,2o,/rr
o
By signing this permit/application, I agree to caII for inspection(s) as required
(726-3769). I state that aII the information on this permit/application is correct
and that I vas provided vith the Vood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I'am installing meets smbke emission standards as set by the 0regon Departnent af
Environmental Quality or the Federal Environmctrtal Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
ilso understand that if I am requesting a prcJ.iminary inspection, the vaII covering
may be required to be removed.
Tu,;l"eL o
gnature
, FOR OFFICU USE
REQUIRED INSPECTION(S L.-- PRELIMINARY u.-
Date of Application:Job #:
Tota1 Amount Collected:
Issued By:
oo d Sto
NSERTu00
20
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Receipt +, /?O/,f
Checked for Deliquencies | ,/
? S/y's7
Uhccked for Ilistorical Status: