HomeMy WebLinkAboutPermit Mechanical 2004-2-17 (2)
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CITY OF SPRlNGFIELD, OREGON
225 F1rrH STREIT. SPRINGFIELD, OR 97477 . PH:(54])726-3753 . FAX: (54])726-3689
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7f/ill - ~Ol\~~~: ~~M l ExpiRE Ifi,H~.W~~~
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~ M IiHOR\I~Ou UN~~ F.~\'f,~ffN'E6~OR
If!!'tl, Date of Application COMME~)2~, ~i;iilnl9 '-I
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Tax Lot
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Phone
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Zip (Yl q 11_
Preliminary Inspection is $45.00 (prior to insert)
Wood Stove/PelletlInsert Permit is $61.75 (inclndes Permit, Issnance Fee, State Snrcharge & Admin Fee.)
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Construction Contractors Registration tL '. . ) JPI :y"c, ado!=;1pw'o _ r"IeS are ." ^"
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By signing this permit/application, I agree to call for aD'ful.!Jl~,ti5w<<sl.ll.s n!q\\Wci~~<:ft~1i~31769)l~p~~~t all
iTlformation on this application Ipermit is correct and tR!rt-"I"~ai\wm,ljdeil:Wi{1i th.,"n\y'Q.od~Si'O~~ ~'reiy
information for wood burning appliances and preliminary 111~~~!q\!l~tl1n(IQlW~,.s.~~!ly..thetb\\,gon Department
of Environmental Quality or the Federal Environmental pffill:c?ton-Agenc)'-al,a 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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r~'ecked for Historical Statu.,
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Sb:u'cd Drive(f:YBuilding FormstWood Stove PennitJ~2.doe
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2004-00186
COM2004-00 186
COM2004-00186
C0M2004-00186
COM2004-00 186
Payments:
Type of Payment
Check
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Receipt #: 1200400000000000213
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Wood Stove/Insert
Minimum/Adjustment Mechanical
-Mechanical Issuance Fee-
Received By
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(;heck Number
Batch Number Authorization Number
Paid By
MARSHALLS INC
17831
City Sf Springfield Official Receipt
Development Services Department-.
Public Works Department'
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Date: 02/1712004 1:27:lIPM
Amount Paid
Item Total:
3.15
4.50
30.00
15.00
10.00
$62.65
How Received
In Person
Payment Total:
Amount Paid
$62.65
$62.65
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