HomeMy WebLinkAboutPermit Mechanical 1996-9-13
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VOOD STOVEIINSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fit th S tL'ee t
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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Job Location:
12&0 WI(}-- OIVI/Ut'lc
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Tax Lot ft: 0 ~7(.m
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Assessors Map J:
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Ol/ner:. ~ q;. ~ rf'~ -sll ~ vV'
Address:JQC-.U Ld tOll('^?"r ~+,
CitY:~){'\~~P~J State: r0P-
Value of Vood Stove/Pellet Stove/Insert:
Preliminary Inspecti~15.0~rior to installation of insert)
Uood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
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Phone: ft: 51.{ 1-7lflf-dJ r; "
Zip Code: q71/77 ,
Type of Inspection Requested:
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Contractor:
Address:
Phone &:
City:
State:
Zip <;ode:
Construction Contractors Registration ft:
Expires:
By signing this peL'mi 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 II/as provided vi th the Vood Stove Safety information for vood burning
appliances and preliminary inspection standards. I further state that the appliance
I am installing meets smoke emission. standaru::; as set by the Oregon Department of
Environmental Quali ty or the Federal Environmental Protection Agency and I agree to
pr~vide the testing approval number to the inspector at the time of inspection. I
also 'understand that if I am requesting a prel.iminary inspection, the vall covering
may be required to be removed.
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FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
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Date of Application:
Job 11:
PRELIMINARY
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Total Amount Collected:
Receipt ft: 2311'/
Issued By: ~ ___
"Checked for Deliquencies:
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Checked for Historical Status: