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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
COMMUNITY SERVICES DIVISION - BUILDING SAFETY
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LIN~
Job Location: ~ ~ 1o-1()
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Assessors Map #: /7aZ 3l{z.." Tax Lot#: tJ33110
Owner: L\ \ \ ~ l.\ '" 'I. \< l\.. \-0
Address: \0 '~, b ~ " LiS,\- . Phone#: "\ Do .:s 10 0 1
City: c;. '? <' \ V'\ l) ( ~ .e. \ 0. State: 0 e... Zip: C\, L\, <l
Value Of~IPellet Stov~ I (,(trz) (please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood StovelPellet/Insert Permit is $15.00 + $ .75 state surcharge + $.45 Administrative Fee + $10.00
Issuance.
Type of Inspection Requested:_WM dOt/lEi ':!;r't!':~ri6rforegon law requires you to
NOTICE: follow rules adopted by the Oregon Utility
THIS PERMrtS<<~tt~'XFln-c 1[= THEWOnl~ ~Jotifi:~tie;~ C~~t€r. Th~s~ f;JI.3s-.:r: ;:.at f\3~h
AUTHORIZE~d9t~~1ER THIS PERMIT IS NOT ~0~~.~,,~~2~0~;~~~~~~~~~~= ~~~9~~~~0~j~
COMMENCEt'lt9:R IS ABANDONED FOR State: calling ~he center.JN~te:.t~~ tel~~ho~e
ANY - 01"\ flA Y ~tHI(J!). numbar .or the Oret18f, Util.ty tJ\3.#ieatl\3n
101.1 ..' I, -, . . . , r:E,enter is 1-800-332-2344).
ConstructIOn Contractors ReglstratIon#: xprres:
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 Wood 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 n,umber 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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Date
FOR OFFICE USE
Date of Application:
REQUIRED INSPECTION(S): WOODSTOVEIPELLET/INSERT
/ 2--/.]. "J /f P
. ,
, PRELIMINARY
Total Amount Collected: 21.. k
Receipt #: !J 3). "5 ~
Job #: q & /s'"{~ 9
~SSUedBY: d Ir/J
Checked for Delinquencies:
Checked for Historical Status:
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