HomeMy WebLinkAboutPermit Mechanical 1993-11-16OREGONclTY OF
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Job Location:
Assessors Map *:
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IJOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fi.fth Street
Springfield, 0regon 97477
SPFlIP-FtELE,
': 0f fice:
INSPECTION LINE:
726-3759
726-3769
234
1 Tax Lot *:
Ovner:A/^ €ft
Address 2 N H4 Phone #:4
Ci ty:Zi.p:
of Uo Stove nser t :
(please circle appl lance
Preriminary rnspection is $15.00 (prior to installation of insert)uood stove/Perret/rnsert Permit is 915.00 + S1o.oo rssuance + $.15
Type of Inspection Requested:ftlfuJ-
Contractor: fn
VaIue
state surcharge.
S tove
Address:Phone *:
Ci ty:State:Zipz
Construction Contractors Registration *:E xpires:
By signing this permit/application, I agree to caII for an ins pection(s) as required(72 6-3769). r state that aIr information on this apprication/permit is correct and
tha t I vas provided vith the l,lood Stove Safe ty information for vood burningappliances and preliminary inspection standa rds. f further state that the appliancef am installing meets smoke emission stand ards as set by the 0regon Department ofEnvironmental Quality or the Federal Envi ronmental Protection Agency and f agree toprovide the testing approval number to t he inspector at the time of inspection. Ialso understand that if I am requesting a preliminary inspection, the vall covering
may eq uired t emoved.
ture Date
FOR OFFICE USE
REQUIRED INSPECTI0N(S): U00D /INSERT PRELIMINARY
Date of Application:/k Qs Job S:a
Total Amount CoIlected:
Receipt *: I Oq I A
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Checked for Delinquencies:
Issued By:
Checked for Historical Status:
S ta te: