HomeMy WebLinkAboutPermit Mechanical 1996-10-31
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VOOD STOVE/INSERT INSPECTION APPLICAtrON
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield; Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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Job Location:
(2.~5?
L.A.). 'OLl;/JA-LT cc::;,\".
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Assessors Map #: /7-o~ -""27-3'2.
Ollner: L-AIL)f!-fir0LE A. f?.,)!-l E
Address: 12. 'lg u.), QUIA'MT S..
City: S(J~\j\.'}hFIFlb State: &~
Value oft"1lo0d StovepPellet Stove(friser1J>~C,OO IX>
Tax Lot ~: ~d/PZ
Phone: #: 71./1o~ .:5lyq
Zip Code: G7c..J77
Preliminal-y .Inspec t ion is $15.00 (prior to ins talla tion 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:
Contractor:
Address:
Phone #:
City:
State:
Zip C;ode:
Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for inspection(s) as required
(726::3769). I state that all the information on this permi t/application is correct
and that I lias provided vith the \lood Stove Safety information for vood 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 Quali ty 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 vall covering
may be required to be removed.
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Signa tUl.e
&Ju.;;;
(O{3t!Qf,
bate
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FOR OFFICE USE
REQUIRED INSPECTION(S): ~DSTOVE2PELLET(1NSCRT)
Date of Application: ~ -"3/-%'
Total Amount Collected: /.<):- ~
PRELiMINARY _ y
Job U: ~/'-/"9~
Receipt #:~~?~
-'Checked for Deliquencies:
Checked
Issued By: ~::_;....
-/ .
for Historical Status: