HomeMy WebLinkAboutPermit Mechanical 1991-2-8
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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.
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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:
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...............
Checked for Delinquencies:
Checked for Historical Status: