HomeMy WebLinkAboutPermit Mechanical 1993-5-5
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
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Address: 'j 74.AU--t"50 Av~ .
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City: ~~/tV~?/e(,,-)
Value of ~d~/pellet Stove~~
(pleas<< circle appropriate appliance)
Job Location:
Assessors Map #:
Tax'Lot #:
~ .C;I'.JU
Owner:
])ON
Phone #:
7?7-IZ/.s:
Zip: 9'7~ 77
State:
~
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Preliminary Inspection is $15.00 (prior to installation of insert) "
Yood Stove/Pellet/Insert Permit is $15.00 + $10;00 Issuance + $.75 state surcharge.
Type of Inspection Requested:
jNsOer
Contractor: p~...-;-~r /r//f"e.TAjO<'.,S.
Address: -?'"/J Jc'/~ ~.oJ:?
. '. ' I '
Construction Contractors Registration #:
,7n9/alJ
Phone #: Z~S-~~'A-
Zip: <7?~~ /
Expires: / -3 - 5'<1-
,
Ci ty: We:::.
State: ~
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
applianc~s 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 th~t' '~m '4 sting a preliminaryinspectidn, the wall covering
~_ r r,e eqqUUir~,t , . ...._CJ . , ,
.~ /'I _ )J 5/S/9j:
/- Sighafure C7 ~y Date /' I
FORbFFICE USE
REQUIRED INSPECTION(S):
YOODSTOVE/PELLE~SE~
5-~-ey3
2f;;,7J'
~ PRELIMINARY
Date of 'Application:
Job #:
9<o.)~
Total Amount Collected:
Receipt #: ~ :a,7~'
Checked for Delinquencies:
Issued By:
~~
---r:
Checked for Historital Status: ~