HomeMy WebLinkAboutPermit Mechanical 1996-11-139
SPClINGFIELf)
0ffice:
INSPECTION LINE:
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFET\. DIVISION
225 Fifth Street
Springfield, Oregou 97477
7 26-37 59
726-37 69
Job Location:(,
Assessor-< Map ll
Ovner:
Add res
Ci ty:
11
q R
tl072ct 33
f,1-
lc(
Tax Lot f;o5
o S ta te:
7/7- q/2Phone: #:
Zip Code:
Phone #
q7/77
Value of Vood el
Prelirfriuary Inspection is $15.00 (prior to instal]ation of insert)
Uood Stove/Pellet/fnsert Permit is $15.00 + $.75 state surcharge + S.45 administrative
fee + 510.00 issuance = 526.20 to
t;)wType of Inspection Reques ted:
Contractor: ?W
Address, 28Zg nnw bn 3?5 -tu{b
7 ru.Qzqo/
///3
te
city: A44LLP State:Zip C.ode
aon".rr*Z-Contractors Registration #Exp i res :F3-q1
By signing this permit/application, I agree to call for inspection(s) as required
(726-3769). I state that alI 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 smoke emission standartis as set by the Oregon Departmenf crf
Environmental Quality or the FederaL Environnrcntal Protection Agency and I agree to
provide the testing approval number to the irrspector at the time of inspection- I
ilso understand that if f am requesting a prc)iminary inspection, the vall covering
equired to be removed
o
ure
REQUIRED INSPECTION(S): U00DST0 /PE
Date of Application:il- B-q"b
Total Amount Collected:2(o.20
Receipt fl:2316 )
DRT PRELIMINARY
Job #:
Issued By:
-Clrecked for Detiquencies ' L-Chccked for Ilistorical Status