HomeMy WebLinkAboutPermit Mechanical 1994-09-09CITY OF SPRINGFIELD, OREGO'V
SPFIi'GFIELD
IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location , 3t5 fv &b t=
Assessors MaP f:7 ^71 . /7
Office z 726-3759
INSPECTION LINE t 726-3769
Tax Lot *t Zo/aa
iOvner: F c
Address '3t5 N. abe
io\State:
Phone: *:I ato - r35 i
Zip Code:q 1 Lt-t
Ci ty:S \r\
Cont
o&(
Value of Vood Stove/Pe1let Stove/Insert:#'it0tiL
Preliminarylnspectionissl5.o0(priortoinstallationofinsert)
vood stove/Pe11ei7i"""rt Permit i:"ii;:00".-'$:i5-ti"t" surcharge * $'45 administrative
i""-.-SrO.00 issuaDC€ = 526'20 totaL
Type of InsPection Requested:
ractor , 6ror\,^o n(
Address , 5'33>. M\oi-ra \+"Phone #: 1qb 'la>>-l
O ( zip code z otlq--1 t
Ci ty:ot State:
Construction Contractors Registration #z )k'7(-t3 Expiresr E ,2
By sign ing this P ermi t/app1 ication, I agre e to caLl for insPe ction(s)AS requi red
(726-376e).I StA te that al I the informati on on this Permit/aPP Iication is correct
- and that I vas provide d vith the Vood Sto ve SafetY information for vood burning
ap pJ-iances and P reliminarY insP ection standards.I further state that the aPPliance
I am installing meets smoke emi ssion standards as set by the oregon Department of
Environmental QualitY or the Fede raL Environmen tal Protection AgencY and I agree to
provi de the testing aPP roval- number to the insPe ctor at the time of inspection. I
e vaLl covering
also understand that if I am requesting a PreliminarY inspection, th
may be required to be re moved.
€
tet
========================-_======-_=================================================__=====FOR OFFICE USE
REQUIRED INSPECTION(S) :LLET/INSERT PRELIMlNARY
Date of APPlication:Job #:
Total Amount coll-ected ' ?6 '7 o
Receipt x,a/43
Checked for De1iqu"n"i"" '
-
Issued BY:
Checked for Historical tatus: