HomeMy WebLinkAboutMiscellaneous Application 1995-7-17
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S~RINGFIELD
UOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Job Location:
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Assessors Map #: /7l'2..3 J1 ~
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Address: 4'f~ 2)A-t'S V
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'S"filA ~ . . State:, ~-, _,_Zip Code:
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Value of Yood Stove/Pellet Stove/+risert: / ~ ,/4 ,) -
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Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge +
fee + $10.00 issuance = $26.20 total
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Tax Lot #:
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Owner:
Phone:~
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City:
$.45 administrative
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By signing this permit/application, I agree to can--t'oY'.....i:n's'pectioif(s) as required
(726-3769). I state that all the information on this permit/application is correct
and that I was provided wi th 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 P~otection 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 required to be removed. '
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Type of Inspection Requested: )C'~-I'_~~-- ~.~~~
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Add,F,eS';: . (? 7 n :2 3 I .I ve~--f 0-1\ R.d 0 E.
('Y' SQ (~_/V\ Stale' f) I?. .
CO;;S-H,uction Contractors Registration #: LJ9flL/Z
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Phone #: (50:1 ') :) '7f:tj>!)lf.. t.f
Zip Cpde: Ci7 50~ ""\
Expires: 4-//- 96 /
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FOR OFFICE USE
Total Amount Collected:
YOODSTO~LLE~NSERT
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PRELIMINARY
REQUIRED INSPECTION(S):
Date of Application:
Job #:
cJc-L) / 22 ~
Receipt
#: JC!342-7 '
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Issued
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Checked for Deliquencies:
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Checked for Historical Status: