HomeMy WebLinkAboutPermit Mechanical 1993-09-24C,ITY OF OFEGO'V
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth StreetSpringfield, 0regon 97477
S- -I]{GFIELD
Office:
INSPECTTON LINE:
726-3759
726-3769
Job Location: 2G 2<,^'N,23&)
Assessors il.p *t rax Lot *, d;O/O*-O
Ovner:
Addressz 2
Ci ty:
4 Phone #: 7Z 6 4,
State:Zipz
Value of Uood Stove/
(please circle d-vD,&ate appli ance
Preriminary rnspection is $15.00 (prior to instalration of insert)I,lood stove/perret/rnsert permit i;'$rs.oo-*-lrtiloo rssuance + $.15
Type of Inspection Requested: p?/ -:- ,/.tlS*Cf
state surcharge.
Contractor:
Address:Phone #:
Ci ty:Zipz
Construction Contractors Registration *:
By slgning this permit/application, I agree to call for an ins pection(s) as required(7 26-3769). f state t hat all informat ion on this application/permit is correct andthat I vas provided vi th the lfood St ove Safety information for vood burningappliances and preliminary inspecti on standards. f further sta te that the appliancef am installing meets smoke emissi on standards as set by the 0r egon Department ofEnvi ronmen tal Quality or the Fede ra1 Environmental pro tection Agency and I agree toprovide the testing approval number to the inspector a t the time of inspect ion. falsoerstand that if f am requesting a preliminary inspection, the vaII coveringrequired to
ture Date
FOR OFFICE USE
REQUIRED INSPECTION( S) :
Date of Application:aJ<.I/ PRELIMINARY
Job *:
--7--
2s,?rTota} Amount Collected:
ReceiPt t:D s1 /
Checked for Delinquencies:
Issued BY:
Checked for tlistorical Status:
CITY OF OFEGO'V
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
t
-rnaFerrELs
I
0ffice:
INSPECTION LINE:
726-3759
726-3769
Job Location:
Assessors Hap *:Tax Lot *:
0vner:
Address:Phone *:
Ci ty:State:zi p3
Value of !lood ove/Pellet Stove/Insert 3
(please circle appropria te appliance
Preriminary rnspection is $15.00 (prior to installation of insert)
I,lood Stove/Pellet/Insert
Type of Inspection Reques
Contractor:
is $15.O0 + $10.00 Issuance + 5.19 state surcharge.
fr-z{- rU
DAE
oo\
Address:Phone *:
City: State:Zipz
Construction Contractors Registration #: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 correci andthat I vas provided vith the llood Stove Safety information for vood burning
appliances and preliminary inspeetion standards. f further state that the applianceI am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Ag-ncy ana f 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 vaII covering
may ired to be
a ure
FOR OFFICE USE
REQUIRED INSPECTION(S): IIOODST0VE/PELLET/TNSERT PRELIMINARI
Date of Application:Job t:
Tota} Amount Collected:\=
ReceiPt t:
Checked for Delinquencies:
sued BY:
Checked
IJ6b
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