HomeMy WebLinkAboutPermit Mechanical 1990-10-11
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: /;2/;) (!tJ.J/Vl.uJ, S p/?.A/J1/1L;ld, GILt,
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Assessors Map ,*: 11 0 ~ :J (,.,Lj LI Tax Lot *: }):2 00
Owner: (}J/)f~/u (/jA1Jl/~~
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Address: I ~ 1;;1.. (l0/J17i;x JA J, S; L2?..I~a jJ ... JJ /0/11. . Phone #: '7 '-/7 - J 6 ~ 6
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City: 3;?fl.....(~~A J'. ~.;V State: (j&/h7YI/ Zip:
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Value of 'Wood StoveAgellet Stov~Insert: if /8' F' <-t. ~
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of insert)
'Wood Stove/Pellet/Insert Permit is $15.00 + '$"-;"T5 state surcharge + $10.00 Issuance
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Type of Inspection Requested: ']J.t1A,;,) \..fJ.af.\'iz1.Jl.eJL~C/)?1~) ,
Contractor: (2;)u:k S' ~ (JYL~~
Address:
Phone #: 3l/ t.{ - SSg ;)....
City:
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State: Zip:
Construction Contractors Registration #: 1-( E1ftO I
Expires: q-, q- q/
By signing this permit/application, I agree to call f9r 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 understand that if I am
requesting a preliminary inspection, the wall covering may be required to be removed.
ep's W/fAti.J(2nd~ )1/J/JU/L-7J1~
Sighature ' /' 0
FOR OFFICE USE
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Date .
REQUIRED INSPECTION(S): 'WOOD~TOVE~/INSERT PRELIMINARY
Date of Application: .J()-l \ -01 '-.) Job #: Cj'() I:J ~~""I
5,
Total Amount Collected: 'J L .J<=:
Receipt #: 1 ~ 4&1 Issued By: SB
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, Checked',for Delinquencies: ../"- Checkep for Historical Status: .---