HomeMy WebLinkAboutPermit Mechanical 1997-8-19
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SPRINCFIELD
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97677'
Office:
INSPECTION LINE:
726'-3759
726-3769
Job Location:
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Ta;: Lot ~: ()').IO)....
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Assessors Map
Ovner: 2.
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Address: /.'1/
Phone: ~: I i./ ,- / 5 .~ 9
City:. ~ ~
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Value of Vood Stove(tellet
State: ()~~ Zip Code:
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StoV';)Insert: l.iDO.DO
"7' 7 <-IT7
Preliminary Inspection is $15.00 (pdor to installation of insert)
Vood Stove/Pell~t!Insert Permit is $15.00 + $.75 state surcharge + $.65 administrative
fee + S10.00 issuance = $26.20 total
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Type of Inspection Requested: (?.,pJ2f),,::!C ~ ~-fi:-,
Contractor: I::k")/'")'(L 0LuJ1/lV" (~ Ah-JIA\
Add ress: " 5 I 'P ltMO-..Yt'+- s r ' Phone ~:
Ci ty: ~12- State: T'l/2. Zip code: '17477
Construction Contractors Registration #:
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Expires:
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By signing .this pelomi t/application, I agree to call for inspection(s) as required
(726-3769). I state that all the information on this permit/application is correct
and .that I vas provided vi th the Vood 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 0{
Environmental Quali ty or the Federal Environnl(:!1ltal Protection Agency and I agree to
provide the, tes t ing approval number to the inspec tor a t the time of ins pee t ion. I
also understand that if I am requesting a preliminary inspection, the vall covering
may be required to, be removed.
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Date
Sitnature
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FOR OFrICI; USE
REQUIRED INSPECTION(S): VOODSTOVE~LET/INSE~
Date of Application: [[//1/97
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PRELIMINARY.,
Total Amount Collected:
2.6. :;C:o
Job !I: 97/ ;Z3.5
Issued Ily: d~.4
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Checked for lIistori.cal ~latus: ~
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Receipt
!I: ? ///"'2
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'"Checked for Deliquencies: