HomeMy WebLinkAboutPermit Mechanical 1995-03-21CITY OF
UOOD STC)VE/INSERT INSPECTION APPL]CATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 ?ifth Street
Sprinefietd, Oregon 91417
SPBINGFlELD
0ffice:
INSPECTION LINE:
1 26-37 59
1 26-37 69
Job Location:Z
Assessors MaP 1l
0vner:
Tax Lot #:
Phone: t:
Zip Code:
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OTzt 77
Phone #:
Zip Code: '
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Value o Vood Stove/Pellet Stove
Preliminary Inspection is $15'00 (pI19t^Io ins-t:11ation of insert)
Uood Stove/PeIlet/Insert Permit it'$fi'00 + $' ,,:-siate surcharge + $'45 administrative
i""-.-Sro.00 issuanC€ = 526'20 total
Type of Inspection Requestedt tOtobTfdy'B
Contractor:
Address:
State:Ci tY:
Construction Contractors Registration *: Expires:
Bysigningthispermit/app.l.i-qstion,Iagre.eIocallforinspection(s)asrequired(726-3769). , ,,t-,"" ,f,;i'Ji t[" intormitiorr or,
-ihi" permit/apolication is correct
and that I vas provided vith if," Vood Stove S"i"ty it'fo''nutibn for vood burning
appliances _a_n.d pr'.i;*i;;ry insp""ij";-siandarcls. r further state that the appliance
I am insralrrng meets smoke "*i;;l;; siandarcts;;;i-UV.ti'",0regon Department of
Environmentar euarity or tr," rua"ial Environrnentar protestion Agency and r agree to
provide the ,"r,i^n-g''upprovat nui["i- to the i"'p*toi -tt the time of inspection' I
arso understand thit if r am ."orl".itg;-p;ii*-i;iv lt'"p""tion' the va,1 covering
,.V U" required to be removed'
=== = == = = = = = == = = == ===== = == = == = === ====== = = ==. FOR
REQUIRED INSPECTION(S PELLET/INSIITT
Date of APP}ication:
Tota] Amount Collected:
Receipt *:, l'/' /'c
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=== = =. = ===== == === ===== ======= = ====== ===== === ==
OFFICE USE
PRELIMINARY
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Job #:
Issued BY:
Clrecked for Historical Status2..-
Checked for Deliquencies: L
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