HomeMy WebLinkAboutPermit Mechanical 2001-2-14
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WOOD STOVElINSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location:
\9.30 {If\-:, lr"\!.eJ.
i j-O"? ~ 53~
Tax Lot#: 0 ~& 00
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Assessors Map #:
Owner: ::::: u____" fA '""
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Address: \ Q <, '" WlrA.t< ".\- .<::::1
Phone#:1i.f4-IXo( - t-l
City:Sf)(",.,'j' C..,;(,-l State: ()L
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Value of Wood Stov~ert: ){:?J0.o ~ . (please circle a~~,u~,;ate appliance)
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Preliminary Inspection is $15.00 (prior to insta{[~ririnj~filisert) , -.,
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Wood StovelPellet/Insert Permit is $15.00 + 1. 05state'sw'charge + $.45 Administri1tive Fee + $10.00
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ssuance. ..I'Ii 't.."." '.1",
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Zip:
97l{;7
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Type of Inspection Requested:
contractor:~
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City: .../VOi"I/!'\O>o. Sta~
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onstruclIon ontractors eglStration: ,I/)" _ xptres:
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B . . tho .tJ' 'I.O/V?:'''''I 'I<~D,~l"tcal~l.ILc~h . . () ired (7263769) I th
Y slgnmg IS perml app lcalIon;' ~~'to. .or an;mspectlon s as requ -. state at
all information on this appii~tion/p~fm'iVisc~fre'it~lind.tha{i'was provided with the Wood Stove Safety
information for wood burning ..ppli~ces..;{d'prelimiriYy'insp~ticiii'standards. I further state that the
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appliance I am installing meets smoke emission stanilards.as set by the Oregon Department of
Environmental Quality or the Federal Enviro';;;'ental Pr~tUti6~...Agg!.cy and I agree to provide the testing
approval Ijumber to the inspector at the lime of inspection. I alsriUnderstand thaI if I am requesting a
prelimin;uy inspection, the wall covering may be required to be removed.
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FOR OFFICE USE
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~RELIMINARY
Address:
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Zip:
REQUIRED INSPECTION(S): WOODSTOVFJPELLETIINSERT
Date of Application: ?. - 1 L\ - () I
Total Amount Collected:-$ ?b , S 0 Receipt #:
01-00/30-0 I
Issued By: 1tJ.b
Job #:
Checked for Delinquencies:
Checked for Historical Status:
225 FIFTH STREEi
SPRINGFIELD, OR 97477
(541) 726-3753
FAX (541) 726-3689
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