HomeMy WebLinkAboutPermit Mechanical 1995-2-6
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFEILD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
Job Location:
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Assessors' Map #:' 17"~ ~-::?3"~ Y
Owner: llftY//7 {~~# ?P/;:;>l!=&:~
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Value of~d Stov)/Pellet Stcive([nsert) /~.-o
Tax Lot #: e:>~ ?e:::::>t::7
Address:
Phone: #:
?2~"'~~S
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City:
State:
~.
. Zip Code:
Preliminary Inspection is $15.00 (prior to installation of insert)
Uood Stove/Pell~t/Insert Permit is $15~00 + $.75 state surcharge +'$.45 administrative
fee ~ S10.00 issuance = $26.20 total
Type of Inspection Requested:
contractor:~~~/tj
Address:
W6If:J'ZJ?~V~ /~~":??
City:
S tate:
Phone. #::
Zip'Code:
Construction Contractors Registration #.:
Expires:
By signing thispermi tlapplica tion, I agree to call for inspection(s) as required'
(726-3769). I state that all the information on this permit/application is correct
and that I was provided wi th the Wood Stove Safety information for wood burning
appliances and preliminary inspection standards. I further state' that the appliance
I am installing meets smoke emission standards as set by the Or~gon. Department of
Environmental Quality or the Eeder~l Environmental Prote~tion Agency and I agree to
provide the testing approval number to the inspector at the time of inspection, I
also understand that if I am requesting a preliminary inspection, the wall covering
may be require9 to be removed. .
. IOt1y{#tt(1~1~#
Slgnature ~'.'
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Date
-----------------------------~---------------------------------------------------------
---------------------------------------------------------------------------------------
FOR OFFICE USE
REQUIRED INSPECTION(S)': '('t1OODSTOVYPELLET~.
PRELIMINARY .
~-~5""
Job #:
9Y~~YtP
To tal Amoun tCoilec ted:-::::l.~.< C$o
Checked for Deliquencies:;
.IssUe~BY: ~~-
Checked for Historical' ~tus:
-- ...
Receipt #: /6.<<:::'?