HomeMy WebLinkAboutPermit Mechanical 1994-10-5
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
City:
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Job Location:
Assessors Map #:
Tax Lot #:
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Owner:
State:
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Zip Code:
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Address:
Phone: #:
Value of Wood Stove/Pellet Stove/Insert: ?~~- ~
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested:~ ~"7~~~ ~c..C e-'/ ~~;:;:---,
Contractor: ~~~ 7~~~::r..:> ~r- ~',
Address: 7<..67 - ~x:z '-re;7/~ Phone #: ~<7.?y- -..7'</,0
City: c~~E'- State: ~.' Zip Code: 7? y~
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Construction Contractors Registration #: ~~~xpires: /t!J-:.:;?e-7r-
By signing this permi t/application, I agree to call for inspection(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 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 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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Date
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FOR OFFICE USE
REQUIRED INSPECTION(S): WOODSTOVEefELLET/I~~
pate of Application: /d:?-~""''7''r
Total Amount Collected: ~ ~
~ PRELIMINARY ~
Job #: .~cr/'~2/
Checked for Deliquencies:
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Issued By: ~~ -
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Checked for Histori2al Status:
Receipt #: f 4 tjtJ5