HomeMy WebLinkAboutPermit Mechanical 1995-10-23
UOOD STOVE/INSERT INSPECTION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Assessors Map #: 1~2. -3./"'~ Tax Lot #: t:::!>~/e:-.:;->
Owner: /~~~,~~:c; ,
Address': ~?2-~ ~~~,.Phone: #:
City: ~P3__ State: ~ Zip Code:
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Value 0~6d Stov~Pellet Stove/Insert: /5'e-~
Job Location:
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Preliminary Inspection is $15.00 (prior to installation of' insert)
Uood Stove/Pellet/Insett Permit is $15.00 + $.75 state surcharge + S.45-administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: _~~ ~~/~ ~~_7~Y~
contractor:a;-~t;~~~_~ ~f/0-~ -://?~~ ~C~.,"ry
Address: ? > 'fil?":3 ~~~'~" Phone #: --:?y~ -~'3>~
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City: ?~~ State: ~.~~ Zip C~de: ~~~
Construction contrac~s Registration #: _~~. Expires:
By signing this permi t/applica tion, 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 tha t I "'as provided ",i th the Uood Stove Safe ty informa t ion for ",ood burning
appliances and preliminary insp~ction standards. I further state that the appliance
I am installing meets smoke emission s,tandards as set by the Oregon -Department 01
Environmen tal Quali ty or the Federal Environmcn tal 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 ",all covering
may be required to be removed. ,.
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FOR OFFICE USE
'REQUIRED INSPECTION( S) :<J700I5'ST~ELLET /INSERT
Date of Application: /p....::2"3-~S
Total Amount Collected: :z~~~~
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PRELIMINARY
Job #:
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Receipt .#: /~3~
Checked for Deliquencies:
Issued' By: . ~~_
,Checked for Histori[~~d:;~~: