HomeMy WebLinkAboutPermit Mechanical 2001-10-5
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SPAINOFIELD
WOOD STOVE/INSERT INSPECTION APPLICATION
, CI1Y OF SPRINGFIELD
, "COMMUNITY SERVICES DMSION - BUILDING SAFETY
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225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759,
INSPECTION LINE: 726-3769
Job Location: 2 "'Z, /...I, QodN.0
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Assessors Map #: 170::> Z7 z- Z.
D~n Mi\\ev
Address: '2 "3 4 ~ K'oJ..'N~ c +,
City: .:sp'f\~ +1eJd.., State: 0((,
Value o~ StovelPellet ~ 2 So 0
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. Tax 1ot#:
03300
Owner:
Phone#:
74/-200t..(
Zip:
.t
j,
(please circle G......v...:ate appliance)
Preliminary Inspection is $45.00 (prior to installation of insert) , \..
Wood Stove/PelletlInsert Permit is $61.75 (includes Permit, Issuance Fee, State Surcharge & Admin Fee).
Type of Inspection Reqnested: New -+I'~\ac.e. ~+ (..+_~ -cl-elyer.ce /...1v<.cw 9.t$kvv-,
Contractor: Cli\'(\"'::> \N\y\<S.\OW D.IS.A. V-e otd. IOv-l^- S~p
AddreSs: 8\q()$ ~'\J\?SOVl ~~, Phone#: -T2.c...-,3&2-
City: C>t-es v,->e.l \ State: oR Zip: 9,L( 2.. Co
Construction Contractors Registration#: ' 5 2 38 (Expires: / / 10 / z DO 'Z.
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By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that
all information on this applicationlpermit is w..~. and that I was provided with the Wood Stove Safety
information for wood burning appliances and prelimin.'Y inspection standards, I further state that the
appliance I am installing meets smoke emission standards as set by the Oregon Department of
:....:.v ment.l Quality or the Federal EIIvironmenta1 :'.v~_";on Agency and I agree to provide the testing
approval number to the in.,...._:.... 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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Signature
/~/.5 /01
Date r
FOR OFFICE USE
REQUIRED INSPECTION(S): WOODSTOVElPELLET/INSERT v;;;.IM1NARY
Date of Application: / r ~I Job #: 0 (-0 (() '7 5 - (:) I
Checked for Delinquencies: - Checked for Historical Status:
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VALIDATION: