HomeMy WebLinkAboutPermit Mechanical 1991-11-6
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~OOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth S.treet
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Assessors Map fi:
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17 03 02 ~ Lj /
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/ ~ Lot fi: OS-<gcro
Job Location:
Owner: ~.t:LJR'i't:!'_ ,Ld~;();4
Address: /0 ~ t70/Ald
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State:/1Re
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Phone fi: -7#6~_"",7 "I C:.
Zip: c:r;P/ 7 7
Value of ~ood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
/.5 t:fT'Zl
preliminary Inspection is $15.00 (prior to installation
~ood Stove/Pellet/Insert Permit. is $15.00 + $ .75 state
p~~
of insert)
surcharge + $10.00 Issuance.
, Type of Inspec t ion Reques ted:
Contractor: -J; ~
Address:
Phone fi:
City:
State:
Zip:
Construction Contractors Registration fi:
Expires:
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 ~ood 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
\ ~;;u~:;;2 ///6/9/
~ignatdre . Date
FOR OFFICE USE
REQUIRED INSPECTION(S): YOODSTO~PELL~~NSERT
Date of Application: 1 ( -fp -1/
Total Amount Collected: .~0;, 70
~ PRELIMINARY
Job fi: q I/?>/ D
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Receipt fi: ~
Checked for Delinquencies:
Issued By:
V'
Checked for Historical Status:
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