HomeMy WebLinkAboutPermit Mechanical 1991-10-29!SPF!,lGFtELE'
CITY OF OFEGO'U
V00D ST0VE/INSERT INSPECTI.,./ APPLICATfON
CITY OF SPRINGFIELD
BUITDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97417 0f fi ce:
INSPECTION LINE:
726-3759
726-3769
Job Location:z
Assessors Map *:Z Tax Lot #:
0vner:
Address:Phone #:-2 4city, ?4z(O?1Z-A state:zip:?7r'77
Value of llood Stove/pelle N(please circl e appropr e app ance
Preriminary rnspection is s15.oo (prior to installation of insert)IJood Stove/Pellet/Insert pernit is $15.00 + g10.00 fssuan"" i-$f.ZS state sureharge.
Type of Inspection Requested:
ove/Inser
Contractor:
Addressz 53 Zz-fz
Ciryt 5,4soaD..=.g21)State. ,.1Y
Construction Contractors Registration #:
Phone *:
2 Expires:=?/zb9,/za/>z
zip:
By signing this permit/application, I agree to call for an inspection(s) as required(126-3769). I state that all informat ion on this application/permit is eorrect andthat I vas provided vith the lJood St ove Safety information for vood burningappliances and preliminary. inspecti on standards. I further state that the applianceI am installing meets smoke emissi on standards as set by the 0regon De partment ofEnvironmental Quality or the Fede ral Environmental Protection Agency and I agree toprovide the testing approval numb er to the inspector at the time of inspection. Ialso understand that if I am r equesting a preliminary inspection, the valI eoveringmay be required to be
b,La.qtsgnaDate
OFFICE USE
REQUIRED INSPECTION(S) : II00DSTOVE/PE
Date of Applicati on /O - Z 7 - 7/ Job *:
TotaI Amount Collected:Fze z-f
,
Receipt #: 21
PRELIMINARY
Checked for Delinquencies:
fssued By:
Checked for Historical Status r /1-
/7b s 2-4