HomeMy WebLinkAboutPermit Mechanical 1999-04-27CITY OF SPRINGFIELD, OREGO'V
SPRIiTIGFIELD
726-3769
Job Location:
Assessors Map #:
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L(l Tax Lot#:0637o
Owner:R or.isen&x I
Address: L,{t e r,;-J Phone#: 1t'4-7- aZO 5
Sorlna fretA State: a€-_J^,=)
fWood StovllPellet stouM (please circle appropriate appliance)Value
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StoveiPellet/Insert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee * $10.00
Issuance.
Type of Inspection
Address:
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consruction congactors Registation#, 4 EZ=8 / txotres: t I tol z no <-'
By signing this permit/application, I agree to call for an inspection(s) as required(726'3769). I state that
all information on this application/permit is correct and that I was provided with the Wood Stove Safety
information for wood burning appliances and preliminary inspection standards. I further state that the
appliance 'i am installing meets smoke emission standards as set by the Oregon Deparfinent of
Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing
approval qumber to the inspector at the time of inspection.I also understand that if I am requesting a
preliminary insPection,the wall covering maY be required to be removed.
l/2,1i 3
Signature D"t" --7-----7
FOR OFFICE USE
PRELIMINARY.-_-
{11
Total Amount Collected: ?[ ?^)n, ol)67 I JIssued By:
checked for Delinquencies:_ checked for Historical Status:-
WOOD STOVB/INSERT
CITY OF SPRINGFIELD foltow
COMMUNITY SERVICES
in
225 Fifth Steet
Springfield, Oregon 97 477
0090.
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