HomeMy WebLinkAboutPermit Mechanical 1993-11-15at''
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UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPrlIi.GFIELO
0ffice:
INSPECTION LINE
726-3759
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OFEGO'VCITY OF SPR
Job Location:2az
Assessors Hap *, /?U,3 \ a^ / / Tax Lot *:/ / Oo-o
0vner:
Address | L-2-C- A,/ ,/z ,<a
City: = 'l 1Z\ -State:
Phone *:Z
Zipz----7 FzVa1ue of Uood Sto nsert:/az>
(please circle appropr iate appliance)
Inspection is $15.00 (prior to installation of insert)Pellet/Insert Permit is $15.00 + S10.00 Issuance + 5.15 state surcharge.
pection Requested:
Preliminary
Uood Stove/
Type of Ins
Contractor:QlrV
Address:Phone *:
Ci ty:State | &a Zip,_
Construction Contractors Registration *:%2-Expires:
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 andthat I vas provided vith the Vood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the applianceI am installing meets smoke emission standards as set by the 0regon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree toprovide the testing approval number to the inspector at the time of inspection. Ialso understand that if I am requesting a preliminary inspection, the vall covering
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requi to removed.,7
ture te
FOR OFFICE USE
REQUIRED INSPECTION(S): v00D
Date of Application:Job #:
TotaI Amount Collected:2:
Receipt #: /DA 7 b
Checked for Delinquencies:
Issued By:
Checked for Historical Status:
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