HomeMy WebLinkAboutPermit Mechanical 1992-08-06SP':lI]{GFIELO
Office:
INSPECTION LINE:
1IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Ftfth Street
Sprlngfleld, 0regon 97477
726-3759
726-3769
CITY OF OREGO'U
Job Location: ,i-t tJ /.5-% 5+.
Assessors Map #:Tax Lot #:€ea
ovner:
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Address: .1,5-.>LI N 3r% sl.Phone *z ) )6- 15 75-
Cl ty:
Value of llood Stove/Pe]Iet St
(please circle appropriate a
Type of InsPectlon Requested:
State: CrR
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Preliminary Inspection is $15.00 (prior to installatlon of insert)
llood stoveTpettltlrnsert permit' i;'$15.00 + $ .75 state surcharge + $10.00 Issuance.
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Contractor: Cq) n ef-
Address: Phone *:
ni rrrr State: Zi p3
Construction Contractors Registration *:ires:
gnature
FOR OFFICE USE
By signlng this permlt/application, I agree to call for an inspection(s) as requlred
(726-3769). t state thai-aII informati6n on thls appllcatlon/permlt ls correct and
ifrat f was provided wlth the llood Stove Safety informatlon for wood burnlng
"fffiun""s and preliminary inspection standards. I further state that the appllance
I'am installing meets "roi<" emission standards as set by the 0regon Department of
Environmental quality or the Federal Bnvironmental Protection Agency and I agree to
provide the testirrg lpproral number to the inspector at the time of inspection' I
also understand that lf I am requesting a preliminary lnspection, the vaII coverlng
may be required to be removed.
t
REQUTRED TNSPECTT0N(S) :
Date of Application:
Total Amount Collected:5,N
Receipt *:5bo>
/INSERT PRELIMINARY
Job *:
Checked for Delinquencies:
/
Issued By:
Checked for Historical Statuss-