HomeMy WebLinkAboutPermit Mechanical 1994-10-19
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: 1'// ;l!oe..;./..ri'dCl.f1 Cltx
Assessors Map #: / ?~'3 ':a::;"~
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Address: I'll '.IIJOJ?/o/.A". ; r1 fJ / ~
City: State:
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J Tax"tot #: d/~~-:>
Phone: #:
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Zip Code:
Value of Yood Stov~ll~t Stove/Inser~ 2-/ /J. 5'/"
Preliminary Inspection is S15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total ?tSCC~ &/~?)r-
Type of Inspection Requested: ..1(;1~,'..:_;.-;:",;./T' ~-;/ ~~..;l:>~~::::
Contractor: /V~//~A:"~{" ?~C ~~...... ~~ C"::/"*'5~.
Address: P-/.f?~ "2?/C3/.e:> Phone #:~~"':?-73'::?/O
City: N.....ej~ _ State: ~/'<r. Zip Code: q/V.:i:9.~
Construction Contractors Registration #: ~~..5"E:xpires: /6'-::?~-"5'S--'
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 tha t I was provided with the Yood 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
may be reqoired to be removed.
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Signature LI' . Date / 0 / / 0
===================~===========================~=====================================
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE~ET/INSERT'\ PRELIMINARY
Date of Application: /p~/.s-9 Y Job #: qt;//e:;;~_~
Total Amount Collected: ~~:2~
Checked for Deliquencies:
_0'
Issued By: ~~~_ /
Checked for Historical ~tus: r-
Receipt #: /5/?-/
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