HomeMy WebLinkAboutPermit Mechanical 1989-12-6
WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: Lj~g ;"::;/O.Jl.JLS!-oYle__ :)'f-
Assessors Map #: /1 tJ3 ~ -=? act
Owner: b ~tL JeftlC-.(VL,s
Address: ~R l3/ae.J:.s .kn~
City: Sof'cL
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Va 1 ue o~WO-od Stov.:;Jlnsert: &00-
(please circle appropriate appliance)
Tax Lot #: tJ1oz..0CJ
Phone #:
1741- 3(j11
Zip: q7 Lj-t(
State:
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Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: ~7.
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 also 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.
~7~'
Signature ~
I c -t - cP Y
Date
FOR OFFICE USE
Date of Application:
Total Amount Collected:
Receipt #: /~T50S
WOOD STOVEIING{Rf'" /5.713
II~I Co/tt?;
.
/0.,5
PRELIMINARY
f?Cj I d-?J I
REQUIRED INSPECTION{S):
I
Job #:
Issued
BY:~
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Checked for Historical Status:
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Checked for Delinquencies:
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