HomeMy WebLinkAboutPermit Mechanical 2003-10-21
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ZZ5 FIlTH STREET. SI'RlNGl'IELD, OR 97477 . I'H:(54] )7Z6.3753 . FAX: (541)7Z6.3689
Assessors Mar
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Tax Lot
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Address .~.-r1l~ r'). ('~ \ff'rl Dr, LL Phone
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Value of ood Sto Pellet Stove/Insert. ~;:J I;::;; - . ~~t*~~e appropriate appliance)
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Preliminary Inspection is $45.00 (prio\,\'iBR~~ F,\) \}~\)t: ~\)~~O\)
Wood Stove/Pellet/Insert Permit is $62t>-~\~} t.,~Ir&tn'i?\)tlsuance Fcc, State Surcharge & Admin Fee.)
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Contractor IlIformation
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Construction Contractors Registration # 9 .Q~~t"in cO?~1{nire..\eOnon
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By signing this permit/application, I agree to cl\\!l~l')'ulln \'i\~m:,~tign(4)ra!i'-~quired (726-3769). I state that all
infonllation on this application /penllit is correct and tlfai'r'was provided with the Wood Stove Safety
infornlation for wood burning appliances and preliminary inspection 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.
Signatun,\ ~ ro 1 L
LIS-
Date
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For Office Use
Date of Application
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Checked for Delinquencies
rhecked for Historical Statu~
Sh:lred Drivc(T:)/Building Fonns/Wood Slove Pennin-OJ.doc