HomeMy WebLinkAboutPermit Mechanical 1994-5-5
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
UGkR
225 Fifth Stree't '
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
J ob Loc~ t ion: 353 .. f!J ll\ds~ . Sr vt fl5.t}eJd.
Assessor~ Map.#: \no~'~~
Owner: TX1\'l~cl. ~,l)(\~'nct' Splde-it
Address: ~'~~ AI /\r-JGsfzjr1e~.
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Tax Lot #:
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Pho:ne
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#: ~z& :C(dl0~
Zip: C/,l/ / /
City: l.~V~Y1~~p[d'
Value of W~ Sto~/Peilet Stove/Insert:
(plea~cir~re appropriate appliance)
State:
PJL
r\ (\ )
Prelimin~ry Insp~ction is $15.00 (prior to installation of insert)
Wood Stove/Pellet/Insert Permi~s $15;00 + $ .75 state surcharge +
Type of Inspection Requested: \.{J\ol QffLlf\(lJL.ll>
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$10.00 Issuance.
Contractor:
\\~
Address:
Phone #:
Ci ty: .
State:
Zip:
Construction Contractors Registration #:".())4 Expires:
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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 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
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Signature , ~~. Date I
FOR OFFICE USE
Checked 'for Delinquencies:
WOODSTOVE/PELLET/INSERT
o. ca.q<\
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. Issued By:. WM
checkld for Historical Status:
Job #:
. PREL~NARY .X
c{4u(d1)
REQUIRED INSPECTION(S):
Date of Application:
Total Amount Collected:
Receipt I: ,\Eh\o~
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