HomeMy WebLinkAboutPermit Mechanical 1994-08-30a4E
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVIS]ON
225 Fifth Street
Springfield, Oregon 97477
SPFTltlGFIELD
0ffi ce :
INSPECTION LINE:
726-3759
726-3769
CITY OF SPR"U$FIELD, OREGO'V
2?Job Location:
Assessors MaP #:
Owner:
Address:
Ci ty:State
Value of l,Iood Stove/Pellet Stove/Insert:
PreliminarY InsPection is $15
Vood Stove/Pellet/Insert Perm
fee + $10.00 lssuance = 526,2
Type of Inspection Requested:,
Contractor:
Address :
Ci ty:
gnatu
REOUIRED INSPECTION(S): V00D
Total Amount Collected ' 7'/' 2 a
Receipt +, //22/
Tax Lot #: O7*>
Phone: #: ?/1-5A
Zip code' <722
Construction Contractors Registration X, /Zi;A;Expires, ,tO28 -?,4
By signlng this permit/app'l'isation, I agree to calL for inspection(s) as required
(726-3769). r state thai'all the information on this permit/applic-ation is correct
and that r vas
- ploriJ"a vi th the l.Iood Stove Saf et-y inf ormation f or vood burning
"ppfflr*Ls and prltlminary lnspection standards. r further state that the appliance
f am installing meets srbke "rlssion standards as set by the 0regon Department of
Environmental quaiiiy or the Federal Environmental Protection Agency- and I agree to
provide the t""tirg-""pprova1 number to the inspector at the time of inspection' I
also understand that if r am requesting a preliminary inspection, the vaII covering
may be requlred to be removed'
State:
te
= = == = == = == === = = = = = = == = == = == == = = = == = = = = = ==-' = = = = = = === = = = == = = = = = = = = -- = = = = = = =
FOR OFFICE USE
,K PRELIMINARY ..{
.00 (orior to installation of insert)
ii li'S15.00 + $.75 state surcharge + $'45 administrative
0 total
A Phone #: 6 7?/a
Zip Code , ?-dO 2-
Job #:q ?8
e>
Issued BY:
Checked for Deliquencies:Checked for Historical S tus:
Date of Application , 8-?P'7 cr