HomeMy WebLinkAboutMiscellaneous Mechanical 1994-10-3
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SPRINGFIELD
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRING FEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759 ,
726-3769
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Assessors Map #: /7-0:r-.2C:;-.~:2
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Job Location:
Tax Lot #: 0 ,/Y6n::::>
Owner:
City:
State:
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Phone: #:. '?7~ -.si?h~
Zip Code: . 7./ 9"?-?
Address:
Value of Yood Stove/Pellet Stove/Insert:
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative
fee + $10.00 issuance = $26.20 total
Type of Inspection Requested: ~t::-L ~
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Contractor:
Address:
Phone #:
City:
State:
Zip Code:
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 permit/application is correct
and that I was provided wi th the Yood 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
may be required to be removed.
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Signa ture --;
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bate
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FOR OFFICE USE
REQUIRED INSPECTION(S):
YOODSTOVE/PELLET/INSERT
PRELIMINARY ~
Job #: '9 Y/2:€ '7
Date of Application:
Total Amount Collected:
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Checked for Deliquencies:
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Checked
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Issued By:/' .~.
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for Historical ~tatus:
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Receipt #:Lr~::??