HomeMy WebLinkAboutPermit Mechanical 1991-9-11
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
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Job Location: /9.tP ~ C#;q/ ~/l"r
Assessors Map#: /7~i/t!:)? ";'2.9 '3.2
Owner: ' ~/7;~ ,T~~
Address: ?#-~~-
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Tax Lot #: /66t!Pt!>
Phone #:
City: ~~?-.D_ State:--p~.
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Value of \Tood Stove~llet Stove/lnsertD ? '< '/ ~
(please circle.ppropriate appliance) .
Zip: ~77' 7?
?-- ?~/ 73,716?4tvG""?~ '
Preliminary Inspection is $15.00 (prior to installation of .insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested: ,~t:Z/.-e. ~ /~S7Aee::<~r~~ .
Contractor: ~#.r-T :srz,;'6/ ~C:::k"~~ ~'':-'':::':C:~#~/tJ:::./I-o.$" ~~~;r .
Address: J/./?.. ~)C2 t;;'-c; / Phone #: tC ~ - 3'2 /b
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Ci ty: (f:=~ ~#C State: ~7!. Zip:
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Construction Contractors Registration #: q~ ~,:s"" Expires: /t7"'-::?e~ /
,
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 YoodStove'Safety information for wood burnihg
appliances and preliminary inspection standards. I also understand that if I am
requesting a preliminary inspection, the wall covering may be required to be removed.
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Sigha t..ure
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FOR. OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE/~~TiINS~ ~
PRELIMINARY
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Date of Application: &f 'l/~/
Total Amount Collected: L//. :z::;-
Job #: e9//d!>t6S
Checked for Delinquencies:
Issued By:
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Checked for Historical Status:
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Receipt #: Q/2~?