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HomeMy WebLinkAboutPermit Mechanical 1994-09-02VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVIS]ON 225 Fifth Street Springfield, Oregon 97477 SPFINGFIELE, 0ffice: INSPECTION LTNE: 726-3759 726-3769 CITY OF SPRINGFIELD, OREGO'V Job Location: Assessors Map #, /m<6-2/Tax Lot #: O 2/> Ovner:a n SfuLJ<--rL, // prelininary Inspection is $15.00 (pf i9r^to install-ation of insert) -.-I,tood Stove/Pellet/lnsert Permit i;'$15'OO + $'75 state surcharge + $'45 administrativeu' fee + 510.00 issuance = $26.20 total Address , "/t tE MA 0!Phone: *:7-g/o I Ci ty:state , ci Zip Code:q?47 7 Value of Vood Stove/Pe11et Stove/Insert:y'ZJ Type of InsPection Req uested: Contractor:0)&-"frL Address:/D Phone #: 637- Ci ty State z f'-f Zio Code: Construction Contractors Registration #: t ,/' 4L 5n', Expi res :7 / By signing this P ermit/application, I agree to call for inspection(s) as required (7 26-31 69)I sta te that a1l the information on this Permit/aPPI ication is correct and that I vas P rovided vi th the I'Iood Stove Safety information for vood burning appliances and Pre Iiminary inspection standards.I further state that the apPliance I- am installing meets smoke emission standards as set bY the oregon DePartment of Environmental QualitY or the Federal Environmen taL Protection AgencY and I agree tion. to prov ide the testing aPProv al- number to the also understand that if I am requesting a P may be required to be r d gna ure inspect or reliminary at the time of insPec inspection, the vaI1 1 covering 1 ?s te ====================================-_============================__========FOR OFFICE USE REQUIRED INSPECTION(S): VOODSTOVE 2'PRELIMINARY Date of ApPlication:z Job *, 4/a3€,D Total Amount Collected:2a Receipt #:". Issued By: Checked for Deliquenciesi----.-Checked f or Historical Status 2 -_ ) ./r>