HomeMy WebLinkAboutPermit Mechanical 1995-11-20
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1I00D STOVEIINSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
...
Job Location: ~~"9 .h-?A-#,pA'
Assessors Map #:. /?-<'~"-:?"7-7 3
Ovner: '1VrAc-y ~ S-b4 S,\M~
Address: "2-lob'1 M~or 'Drille...
City:, SPviV\o:/J,dd. State:
Value of 1I00d Stove/Pellet Stove/Insert:
7!A-.
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Tax Lot #:
~c:>B~
Phone: #:
iLf4-1D02s'
17t!T7
o~
-:11 ~CYO
Zip Code:
Preliminary Inspection is $15.00 (prior to installation of insert)
1I00d Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
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Ci ty: EL/Vi~~
Type of Inspection Requested:
State:
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Phone #: ~ - =3' :?/~
Zip Gode: ~;>~~
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Address:
Construction Contractors Registration
Expires:
By signing this permi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/ap~lication is correct
and that I vas provided \lith the 1I00d Stove Safety information for \lood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quali ty or the Federal Environmcntal Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspection, the \lall covering
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1/-20.15
Date
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FOR OFFICE USE
REQUIRED INSPECTION(S): 1I00DSTOVE~T/INSE~ ~ PRELIMINARY
Date of Application: 1\' '2.-O.~S Job #: 9~/$/o
Total Amount Collected: --26.::2.~
Issued By: 4~ ,
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Checked for Historical Status:
Receipt #:~":?'?
'-Checked for Deliquencies: