HomeMy WebLinkAboutPermit Mechanical 1991-11-13CITY OF OREGO'V
TIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 22 qs /ve 3,/ 5-
Assessors Map #:-2 Tax Lot *:
Ovner:Z C//
Address:*Phone f,: 2 ^dSa
Ci ty:State: />4 zipz ? ? 722
Va1ue of llood Stove Insert:
(please circle ap propr te appliance
Preliminary Inspection is $15.00 (prior to installatlon of insert)
llood Stov"Tp"ttltZlnsert permit' ls- $15.00 + $ .75 state sureharge + $10.00 Issuance.
Type of Inspectlon Requested:
Contractor:)
Ci ty:State:zi p3
Construction Contractors Registration #:c1e /?y'iresr 4Z:-?=
By signlng thls permit/application, I agree to call for an inspection(s) as requlred
<iZO-5lOgj. I siate thai'all lnformation on this appllcatlon/permit is correct and
itrat f was provlded with the llood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state that the appllance
I'am installing meets smoi<e emission standards as set by the Oregon Department of
Bnvironmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing "pproual number to the inspector at the time of inspeetion. I
also understand ttrit -it I am requesting a prellminary lnspection, the vall coverlng
be requ ired to be removed.
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ure
//-/3 - 7/
Date
FOR OFFICE USE
REQUTRED TNSPECTTON( S) :
Date of Application://-€,2
Total Amount Collected:a25:?
Receip t*: Oa
* PRELIMINARY
Job *:q//
1--'/-
Checked for Delinquencies:
Issued By:
Checked for Hlstorical Status:
seRrxGrteLo
225 Ftfth Street
Springfield, Oregon 97477
Address 2 c,,^ {^f----t /%E y'VE- Phone #:
s-