HomeMy WebLinkAboutPermit Mechanical 1993-8-25
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YOOD STOVE/INSERT INSP~CTIONAPPLICAT~ON
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street .
Springfield, Oregon 97477
. ,Office: ' 726-3759
INSPECTION LINE: 726-3769
Job Location: --t<~ S S- *"~__
Assessors Map #: /'?c:J2 .3' ~ ~r ~
Owner: /.n~7/A) ~~
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Address: -P31ff~ _M?&e
Ci ty: S:;P~) State:,,/jj,e'
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Tax Lot #:
0CJ1
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
Phone #:, '7 2.. ~ - 8<106..
,zip: ~ 7,~7.e
Preliminary-Irispection is $15.00 (prior to installation of ins~rt)
Vood Stove/Pellet/Insert Permit is $15.00 + $10~00 Issuance ~ $.75 state surcharge.
Type of Inspection Requested:
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Contractor:
Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was provided with the Vood Stove Safety information ,for wood burning
appliances and preliminary inspection standards. I furth~t siate that the appliance
I am installing meets smoke emission standards as set by the Oregon Department of
Environmental Quality or the Federal Environmental Protection Agency and I agree to
provide the testing approval number to the inspector at the time of inspection. I
also understand that if I am requesting a preliminary inspectici'n,the wall covering
WJM;;:emoved.. 4v~ .:<J;/,",?J
Y Signa ture _: ',' " , Da t'€ .
FOR OFFICE USE'
REQUIRED INSPE'CTION(S)~np$T~~~p. ",,,,'~i>
Date of Appli~atibh: '
Job #:
, PRELIMINARY" ~
q ~ Ii 4. /
/ '-"'1'1
Total 'AmountCollec ted:'
/ S. 0-0
Receipt #:
!~P(_/J'
Issued By:
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Checked for Delinquencies:
~
Checked for Historical Status: