HomeMy WebLinkAboutMiscellaneous Application 1991-12-2
YOOD STOVE/INSERT INSPECTION APPLICATION,
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
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Office: 1726~3759 ,
INSPECTION LINE:') IZb':'3769l_
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Assessors Map #: J J 0 ~ ?:> ').y '-:-j
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City: .<SpV'1 V\J~pJ.d State:
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
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Job Location:
Tax Lot tl:
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Owner:
:
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Address:
Phone #:
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Zip:
C1,"-I751
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit' is $15.00 + $ .75 state surcharge + $10.00 Issuance.
Type of Inspec t Ion Reques ted : P /'I g . .p 1~ , ~~ "l..1.:'(;- Ov.-"'rJ6
Contractor:
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Address:
Phone #:
City:
State: .'
Zip:
Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that'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 r!quired,to be removed.
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U FOR' OFFICE USE
Date of Application:
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. Job #:
PRELIMINARY ~
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REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
Total Amount. Collected:
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Receipt #:
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Issued By:
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Checked for Delinquencies:
Checked for Historical Status: