HomeMy WebLinkAboutPermit Mechanical 1993-10-14
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: ~&::> -5 ~~e-e';;;-
Assessors Map #: //-~2~-~
Owner: ?::-~ ~~I~
Tax Lot #: 6~ y~
Address:
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Phone #: -:; 7'6'- 7::i'~
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City: ?)~_ State:
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Value of Wood Stov~llet' S;;'e/Insert~
(please circle appropriate appliance)
Address:
Type of Inspection Requested:
Contractor: ~~/~~
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75 state surcharge.
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State: C?~.
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Phone #: I/gty ''75~
.zip: q,,;:>V~...:>-
City:
Construction Contractors Registration #:
Expires:~-9 ?
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 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 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
FOR OFFICE USE
REQUIRED INSPECTION(S):
YOODSTOV~~ET/INS~
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PRELIMINARY
Date of Application:
Job #:
Total Amount Collected:
Receipt #:
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Issued By:
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Cnecked for Historical
Status:
Checked for Delinquencies: