HomeMy WebLinkAboutPermit Mechanical 1993-06-16I,IOOD STOVE/TNSERT TNSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
SPFINGFIELD
0ffice:
INSPECTION LTNE:
726-3759
726-3769
CITY OF OREGO'V
Job Location:7-qsq )3q s,,q S,T
Assessors Hap *:
ovner: D^*- o-
Z Tax Lot *: 1/O3
G.or,,,+ il*.,
Address .7:q(tt f\) 3q:"Sr Phone *:17J*- 5S7-(
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Soo ,AJCFTELb)State:Ca zip , q+7)
Value of llood Stove
(please circle 23?sensert:
appro <t appli ance)
Preliminary rnspection is 915.00 (prior to installation of insert)llood stove/Pelret/rnsert permit is 915.00 + S1o.0o rssuance + $.15 state surcharge.
Type of Ins
Contractor:
pection Requested:
Address : 57 f ttJtt Phone *. (-Y ? - Oq 6{
State:zipt Q)(OL
Construction Contractors Registration *:\72 Expires:
By signing this permit/application, I agree to call for an inspection(s) as required(72 6-3769). I state that alI informat ion on this application/permit is correct andthat I vas provided vith the llood St ove Safety information for vood burningappliances and preliminary inspecti on standards. I further state that the appliancef am installing meets smoke emissi on standards as set by the 0regon Department ofEnvironmental Quality or the Fede ral Environmental Protection Agency and I agree toprovide the testing approval number to the inspector at the time of inspection. Ialso understand that if f am requesting a preliminary inspection, the vall covering
may be required to be removed
S gnature Date
FOR OFFICE USE
: €dc.Oa
l}et Stove
REQUIRED INSPECTION(S): lI00D
Tota1 Amount Collected t 2 q.75
Receipt fl:7o f
PRELIilINARY
Job *:
Issued By:
PELLET
Checked for Delinquencies:Checked for Historical Status:
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Date of Applicationz lb -/(L- 7 3 ??maz/z