HomeMy WebLinkAboutPermit Mechanical 1991-6-12
I
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Flfth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
City:
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Map #: \ ~ D '2 O~ I "0
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Tax Lot #:
o?({OO
Job Locatlon:
Assessors
Owner:
Address:
Phone #:
7(.(7-0155
Zip: 9?C(7 g
State:
OK-
#900 00
Value of Yood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state
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surcharge.
Type of Inspection Requested:
Contractor:
1~
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Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
By signlng thlS permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was provlded with the Yood Stove Safety information for wood burning
appllances and preliminary inspection standards. I also understand that if I am
requesting a preliminary inspection, the wall covering may be required to be removed.
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.Si~a-ture
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Date
FOR OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE/PELLET/I~R~
1,-\?-9(
Total Amount Collected: -$?-(., "2- (
Receipt #, /)03c... /
Date of Application:
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Job II: q I /),C;<g 2--
PRELIMINARY
Checked for Dehnquencies'
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Checked for HistOrIcal StatusV'
Issued By: