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HomeMy WebLinkAboutPermit Mechanical 1991-2-8 . . VOOD 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: Il/75 /1.1 It- Sf- Assessors Map 11: 1-t1l0/7lo~?/ Owner: ' V.p bh t' p_ Seh / UJl i:--P J, Fe r Address: / t/ 7 c; ;v A<;r City: 5p ('rei State: {jf2- Value of Vood StoveePelleJ:gtove/lnsert::It 2DOO. C5ZJ (please circle appropriate appliance) Tax Lot 11: () z..-Z-cJ() Phone 11: 7Lftl-03fo{) Zip: 97L/77 Pr.eliminary Inspection is $15.00 (prior to installation of .insert) Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge. Type of Inspection Requested: Contractor: /Ji;1)M V P,d(d f5-b1/~ Address: Phone 11: City: State: Zip: Construction Contractors Registration 11: Expires: 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 Vood'Stove Safety information for wood burning appliances and preliminary inspection standards. I also unders,tand that if I am requesting a preliminary inspection, the wall covering may be required to be removed. ~h;".I~~ Srl,J.ufl.1>rh.l;"/ SIgnature .;).-1<-9/ Date' FOR. OFFICE USE REQUIRED INSPECTION(S): VOODSTOVE~INSERT ~ PRELIMINARY Job 11: q/O 10 ~'. Date of Application: 2-~g -"1/ Total Amount collected:JW~4? .~~ let zZ-z) Receipt 11: Issued By: / /) >v\JV'.L ............... Checked for Delinquencies: Checked for Historical Status: