HomeMy WebLinkAboutPermit Mechanical 1999-09-29WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97 477
SPFIttlGFIELO
Offtce: 726-3759
INSPECTION LINE: 726-3769
CITY OF SPR OREGO'V
Job Location' i ?>'7
Assessors Map #: / )d2274>24
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Tax Lot#a2,
Address:'7,, *r. 54,Phone#: 726-"-/29
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Value of Wood ?'lS (please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stovei?ellet/Insert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
Type of Inspection rna-
Contractor:,'n S
Address:3qz -41 3/
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Construction Contractors Registration#:(9 2oa /g
By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that
all information on this application/permit is correct and that I was provided with the Wood Stove Safety
information for wood burning appliances and preliminary inspection standards. t further state that the
appliance'i am installing meets smoke emission standards as set by the Oregon Departrnent of
Environmental Quality or the Federal Environmental Protection Agency and I agree to provide the testing
approval number to the inspector at ttre time of inspection. I also understand that if t am requesting a
preliminary inspection,covering may be required to be removed.
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Date
FOR OFFICE USE
REQUIRED INSPECTION(S):
Total Amount Collected: 2Z - fu Peceipt #:
Job #:
PRELIMINARY
Issued By:
Checked for Delinquencies Checked for Historical Status
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Date of Applicatior.: ? ^7a ^??