HomeMy WebLinkAboutPermit Mechanical 1993-9-24
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
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Office:
INSPECTION LINE:
726-3759
726-3769
Job Location:
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Assessors Map #: I?~;J --:2~ '":j'Z
Owner: C:#~CEs- ~ UC~P'?#-/t?
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Value of Wood Stove.<te11et Stove/lns~ ;;{/$3'. ~
(please circle appropriate appliance)
Address:
City:
State:
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Tax Lot #: O~~6
Phone
#: ?7-'..G=- 5'9 ~
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Zip:
Preliminary.Inspection is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $.75 state surcharge.
Type of Inspection Requested: :~fr~..?"-=;/' G.1.;??)"':.~/~
Contractor: /t/At77t:7h"#C- ~~cc:::: c:.A'"A"-'-=-/'YS' .
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Address: ? o2!i~' ;;2.7't:::$/
City: e~.Ar~", State: ~;?:.
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Construction Contractors Registration #:~~~
Phone #:~:6 r 3.::G-/~
Zip: q7~ :2..
_Expires: /~-.:?9-5'3
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 Wood 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 Ouality 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
ma~b~quired to be removed.
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Signature Da1:e .;
FOR OFFICE USE
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ecked for Historical Status:
REQUIRED INSPECTION(S): WOODSTOVE/PELLET/INSERT
Date of Application: ~~::Z4( ~Ji179 Job #:
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Total Amount Collected: /5':'=
Receipt #: /L? 3-&c>
Issued By:
Checked for Delinquencies:
PRELIMINARY
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