HomeMy WebLinkAboutPermit Mechanical 1995-08-25UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
ipringfield, Oregon 97477
Job Location:S 31*r
Assessors MaP *:
SPFII.GFIELD
0ffice:
INSPECTION LINE:
726-3759
726-3769
-Io.t
CITY OF SPR OREGOA'
{us0vner:
Ci tY:
Cons t
,-)
Address:S ql^Phone: *:
Zip Code:S 6 OO
C]?LN
] ,.0, administrative
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State:Ci tY:
Value of Vood Stove tove/
PreliminarY InsPection is
Vood Stove/Pellet/Insert;;;-.-iro.oo issuance = $
S15.00 (prior to installation of insert
p:;ii-i;'$ii.0o + $'75 state surcharge
26.20 total-
(r
Type of InsPection Requested:
Contractor:
Address
i Yv1
Phone *:qtl
Zip Code:
PRELIMINARY I
Issued BY:
State:
By sign ing this Permi t/app lication, I agree to call for insPection (s) as required
ruction Contractors Registration *t 9SIf ( ExPires:
FOR OFFICE USE
REQUIRED INSPECTION(S): VOOD
Date of APP1ication:Job #:
Total Amount Collected:
(726-3169).I state t hat aI I the information on this i t /app1i ca tion is correctperm
i-nf ovas provided vith the Vood Stove Safety rmation fo r vood burning
q
e
appl iances and P reliminarY ins pec tion standards'I further state that the apPl ianceand that I
Iam ins talling meets smoke emlS sion standards as set by the Oregon DePartmen tof
Environmental QualitY or the Feder a1 Environmental Protection AgencY and I agree to
provid e the testing aPP rovaf numbe r to the insPect or at the time of inspection. I
also un de rstand that if I am reques ting a PreliminarY inspection, the va1l covering
may be requ i.red to be removed'
A
te
P,
Receipt +, / 98)O
Checked for Deliquencies:
elIe t sert:
/INS
?o
Checked for Historieal Statust_-
Tax Lot *, OA-trlO-S
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