HomeMy WebLinkAboutPermit Mechanical 1994-8-25
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726_~~4~f','
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726-37, U"
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Job Location: 70'3</ tY7~/Aj S'r:' 5fte.JAX.F"IF)..)) ~~.
97t./7~
Assessors Map #: rtR.<J.J SHJ-r7
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Tax Lot #: ac qf'\(')
Owner: (?", J
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Address: 71) 3 <I
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(V\. A /IV 5 'f.
Phone: #:
7tf 7-LJC1 0 /
97<172
City: :5fRJI,)t. Cltr~'P
State:
Ole
Zip Code:
Value of Vood Stove/Pellet Stove/Insert:
-~~
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $,45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: JL/C1A) ~~l>
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Contractor:
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Address: 7D3t./ /Y'MoJ
City: 5PJ!JAJ(,.'{)~J..."D
$7":
State: D/f!.,
Phone #: 7'17- 090/
Zip Code: 9?4'7'is '
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/application is correct
and that I was provided with the Vood Stove Safety information for wood 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 Quality or the Federal Environmental 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 wall covering
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Date-<=-). -
/99/
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FOR OFFICE USE
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Date of Application:
Total Amount Collected:
Receipt #: \bA\rb
Job #:
PRELIMINARY
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REQUIRED INSPECTION(S):
Issued
Checked for Deliquencies:
Checked for Historical Status: