HomeMy WebLinkAboutMiscellaneous Application 1996-12-5
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SPRINGFIELD
\1000 ST(lVEIINSERT INSPECTION .APPLICATION
CITY OF SPRINGFEILO
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726'-3759
726-3769
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Job Location: -?"/&1? P~/?7
Assessors Hap g: . /7....e::>~... ~?.. '3'":3
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Ovner: ,;5~~~~/j.-- /~L0~~J:-
Address: _"?~ I'??~/?~ ~....
City: . ~~.. State: ~~?...
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Value of \lood Stove/Pellet Stove/Insert: ~~_
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Tax Lo t ~: e:::::'/;?/,Y
Phone: #: -7Y~- ~~~~
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Zip Code:' ~?7/7t!3
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Preliriiina,t-y Inspection is $15.00 (pl"i<:ir to installation of insert)
\lood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + S10.00 issuance'" S26.20 total~~~~ ~~" ,
Type of Inspection Requested: ,~t<:~y~~~_~..;~~__~ 'CC'L~.?-~/./d!;'\
Contractor: . ~_/~~
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Address:
Phone 1::
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City:
State:
Zip C;ode:
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Construction ContractorsR~gistration #:
Expires:
By signingthispermi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all th~ information on' this permit/ap~lication is correct
and .tha t I vas provided \Ji th the \lood Stove Safety' informa tion for \Jood burning
appliances and prel~minary inspection standards. I further state that the appliance
I am installing meets smoke .emission standanhas set by the Oregon Department of
Envi ronmen tal Quali ty or the Feoeral Environmcn tal Pro tee t ion Agency and I agree to
provide the testing approval 'number to the inspectoI:" at th~ time of inspection. I
also understand that if I am requesting a pI:"climinary inspection, the \JaIl covering.
may be required to be I:"emoved.
M
ignature ~
1-;,-- S~ - C; t5
Date
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FOR OFfICE USE
REQUIREOINSPECTION(S): \lOODSTOVEcrBLLE~INStRT
Date of Application: /7-5....... ~
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Total Amoun t Collected: ~6'..::?~
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PRELIMINARY -,
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Job II:
q~/62 ;,
Receipt I: "2?J"~
Issued By: ~~_
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Checked for His tori,cal ~ tus:
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'~hecked for Oeliquencies: