HomeMy WebLinkAboutPermit Mechanical 1991-11-15WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Ftfth Street
Springfield, Oregon 97477
SP,tI'{GFIELD
Office:
INSPECTION LINE:
726-3759
,.726:3769' .
CITY OF OREGO'V
Job Location:tb4 5 tTt^ ?1ru-n-,
Assessors Map *:t-t o?;V(eZl
Ovner:
Tax Lot *: i.;
Address:0 Phone #:
Ci ty:State:.Zipz q
Value of lIood Stove/Pellet Stove/Insert:14 pDb, qp
(please circle appropri ate appliance) "
Preliminary rnspection is $15.00 (prior to installatlon of insert)
l.Iood Stove/Pellet/Insert Permit'is $15.00 + $ .75 state surcharge + $10.00 Issuanee.
Type of Inspectlon Requested:It l'/l"n *1ta-. l{r",Slzr,rct;>,T
Contrac tor:
Address:Phone fi:
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City: State:
Construction Contractors Registration #:
ZIpz
lres:
PRELIMINARY
Job *:
By signlng thls permit/appltcation , I agree to eaII for an ins pection(s) as requlred(726-3769). I state that aII lnfo rmation on thls appllcation/permit is correct andthat I was provided wlth the Ifood Stove Safety information for wood burningappliances and prelimina ry inspe ction standards. I further st ate that the applianceI am lnstalling meets s moke emission standards as set by the 0regon Department ofEnvironmental Qualit y or the t'ederal Environmental pro tectlon Agency and f agree toprovide the testi ng approval number to the ins pector at the time of ins pection. Ialso understand t hat if f am requesting a prellminary inspection, the vaII coveringmay be required to be removed
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OFFICE USE
REQUIRBD INSPECTION(S) :
Date of Application:
Total Amount Col1ected:
Receipt *:/3
LLET/
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fssued By:
Checked for Delinquencies:Checked for llistorical Status:
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