HomeMy WebLinkAboutPermit Mechanical 1993-07-01I,IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SPRINGFIELD
Office:
INSPECTTON LINE:
726-3759
726-3769
CITY OF SPR OREGO'V
Job Locat ionz ?(^tL(i)ZO 5 t) A F,
Assess
0vner:
ors Map *:03
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Tax Lot #:03Sr-D
Address z ? (^4f IO Z\3 Phone *z l{7 - OZ|T
State:zip: q7rfi')
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appropr app ance)
(prior to installation of insert)is $15.00 + $10.00 Issuance + $.15 state surcharge.
Type of Inspection Requested:/n.* f,*tat
Cont rac tor:
Address:I Phone *, <-Y3-Ccit-Y
Ci ty:2-t
Value of lJood Stov
(please circle
iminary Ins
Ifoo
Ci ty:
.00
State:zi p r Q4oZ
Construction Contractors Registration *z S'7 ZC_O Expires:
By signing this permit/application, I agree to call for an inspection(s)as required(72 6-3769). I state that all informat ion on this application/permit is correct andthat I r^,as provided vith the llood 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 oregon Department ofEnvironmental Quality or the Federal Environmental Protection Agen cy and I agree toprovide the testing approval number to the inspector at the time o f inspection. Ialsounderstand that if I ting a preliminary inspection, the vaII coveringmay be required to be removed.
IJ -f,ril firJgnatureDate IFOR OFFICE USE
REQUIRED INSPECTIoN(S): IJ0ODSTOVE /PELLET/INSERT \- PRELIHINARY |-
Date of Application:'7 - t-1=Job *:a
TotaI Amount Collected:IL ol
Ort
L \tvReceipt *:fssued By:
t t'-
IIet Stove/fnser
nsert Permie
Checked for Delinquencies:Checked for Historical Status:
S"r)G Plr:LA