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
-_
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