HomeMy WebLinkAboutPermit Mechanical 1993-12-20ATY OF OPEGO'V
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAPETY DIVISION
225 Fifth StreetSpringfield, 0regon 97477
SPRI,rlGFIELD
0ffice I
INSPECTION LINE:
726-3759
726-3769
Job Locat ionz UDL l.)t?b
Assessors Hap *:Tax Lot *:-53on
Ovner:
Address:Phone *:
Ci ty:EA State:zrez Q7{?7
Value of llood St ,.,I-z&s(please circl e appropr ate appliance)
Preriminary rnspection is S15.oo (prior to instarration of insert)Ilood stove/Perret/rnsert permit is 915.00 + g1o.oo rssuance + $.15 srate surcharge.
Type of Inspection Re ques ted :
Contractor:
Address:Phone *r-6L7- o€/b(
Ci ty:State:zip: q7W7-
Construction Contractors Registration * 3 q///<-Expires:
By signing this permit
(726-3769). I state tthat I r^ras provided vi
appliances and prelimi
f am installing meets
Environmental Qualityprovide the testing ap
also understand that i
may be required to be
/application, I agree to caII for an ins pection(s) as requiredhat all information on this application/permit is correct andth the llood Stove Safety inf ornation for vood burningnary inspection standards.I further state that the appliance
smoke emission standards as set by the 0regon Department ofor the Federal Environmental Protection Agency and f agree toproval number to the inspect or at the time of inspection. Iflamrequesting a preliminary inspection, the vall covering
tz/zo / qS
S gnature Datef
t
5
T
FOR OFFICE USE
et St
REQUTRED TNSPECTION( S) :
Date of Application:2-2
Total Amount Collected:zf." J-
Receipt *:Issued By:
---''' PRELTHTNARY
Job l*:^)
Checked f or Delinquencies z t--'Checked for Historical Status:
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