HomeMy WebLinkAboutPermit Mechanical 1994-9-26
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location: \ ~C\PJ \ HCU't\h1I ",\,J.:),(,\l ~
Assessors Map #:~ l\ Tax Lot #: rA~
Owner: ~ ~ \ \) t.) (\n<:Om
Addres~: \~<?>~~' ~ Phone: #:
City:~~~lrt State: nf\ Zip Code:
Value of V:od Stove~ove/Insert: ;2)~.~
f) 4\ (). f) ?!O<o
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Preliminary Inspection is $15,00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $,75 state surcharge + $,45 administrative
fee + $10,00 issuance = $26,20 total
Type of Inspection Requested:\ ~J\"~ <:\~~l!lht.>~s..O).t
Contractor~ ffit\r\-ro ~ ~,1-(')\ (\ -.
Address: \S,"\).~rm\f) _ - Phone #: \o~~ .?2\O
City: <f'DC\9J\9..- State: \ ~ Zip Code: qw)9_
construc~ion C~-tractors Registration #: ~ Expires: \().?p>-<=\4
By signing this permit/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 with the Vood 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.
<tgnatu~~ /)Pf_{ovlt~ Date .
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FOR OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE~LET/INS~-:> ~ PRELIMINARY ~
Date of Application: q. 91o.~ Job #: q4\~
4\-'LD
Issued BY~\J1>...--
Total Amou:tA~~~ted:
Receipt #:~O
Checked for Deliquencies:
DG~
Checked for Historical Status: