HomeMy WebLinkAboutPermit Mechanical 1995-11-06UOOD ST(IVE/INSERT INSPECTION APPLICATION
CITY OF SPRINCFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
SPRINGFIELO
0ffice:
INSPECTION L]NE:
7 26-37 59
7 26-37 69
CITY OF OF
/>Job Location:
Assessors Map lt:L Tax Lot #:
Ovner:
Address:Phone: #:
Zip Code:
Z
Ci ty:
Value of ilood Stove/Pe11et Stove/fnsert:
Preliminary Inspection is S15.00 (prior to installation of insert)
Uood StoveTPellet/Insert Permit is S15.00 + $.75 state surcharge + $.45 administrative
fee + 510.00 issuance = 526.20 total
Type of Inspection Requested:
Contractor:
Address:-z-Phone #:/e g -n 5ss
Ci ty:Ez<a State: ).1 Zip cpde, ? 7y'A L
Expires: _
may be r ired to b removed.
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State:
ure Date
, FOR OFFICU USE
REQUIRED INSPECTION(S) :
Date of Application:
Total Amount Collected:
Receipt *: ,/ ?,{/1
vooosrovEzarf,flffiDr L/\_____:,-
It /a,/>,f Job #:
PRELIMINARY
Issued By:
/ lza?o
Chccked for Historical Status:
Construction Contractors Registration #:
By signing this permit/application, f agree to call for inspection(s) as required
(726-3769). I state that a1I the information on this permit/appli.cation is correct
and that I vas provided vith the Vood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I'am installing' meets smoke emission standartls as set by the Oregon Departmenf crf
Environmental Quality or the Federal Environnicutal Protection Agency and I agree to
provide the testing approval number to the iuspector at the tlme of inspection. I
ilso understand that if f am requesting a prcJiminary inspection, the va1I covering
Checked for Deliquencies 2 L --'""