HomeMy WebLinkAboutPermit Mechanical 1994-05-20ITOOD STOVE/INSERT INSPECTION APPLTCATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
sPRr.'\F|ELD
0ffice:
INSPECIION LINE:
726-3759
726-3769
-OREGO'VCITY OF SP
Job Location:
Assessors Map *:2
o 7 7'7
Tax Lot *: *Eb =_
0vner:p A
Address:. 272Srv jlsl-
Cilyz :5,-n ,o"" tr la State:a"'K ,
Value of llood Stote/Pe1let Stove/Insert I Z 4ad*(please clrcle appropriate appliance)
Preliminary .1S
llood St
S gnature
FOR OFFICE USE
Phone *z 15o31 7 r'7-4q/P
Zip:q7477
S15.00 (prior to installation of insert)
Permit is $15.00 + $10.00 Issuance + $.15 state surcharge.
Type of Inspection Requested:
Contractor:
Address:7 O. V Zf enone *z 1#?a*V7,/O
Ci ty:AE,dzr4:State:,4'3 zi pr 4n.eZ
Construction Contractors Registration *t ?6=? nxpires z .o *8€7
By signing this permit/application, I agree to caII for an inspection(s) as required
(726-3769). I state that all information on this application/pernit is correct and
that I vas provided vith the llood Stove Safety infornation for wood burning
appliances and preliminary inspection standards. I further state that the applianceI am installing meets smoke ernission standards as set by the Oregon Department of
Environmental Quality or the Federal Bnvironmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the vaII covering
may be ired to
{- a 6
Date
t/Inser
REQUIRED INSPECTION(S) :
Date of Application: )*Zo€ f Job *:
Total Amount Collected:4/.za
Receip t *: /Ze?Z
c--- PRELTHTNARY c=-
Checked for Delinquencies:
Issued By:
cked for Historical Status: