HomeMy WebLinkAboutPermit Mechanical 1990-5-22
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SPRINGFIELI)
WOOD 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: 5 z?9 Ci1n'-fh; C( (!j-
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Assessors Map #: (70 263 ?:..:>L)
Owner: B.f"d v / c IL Cf- t+a V )~ V\CA
Address: -5 Z? 1 ~ Vl~' u... c::J-
City: ~rll\~/J
Value Of~Od Stov~ZPellet Stove/InsertJl !;Z-OZ>.oo
(plea~~ ~}rele appropriate appliance)
Tax Lot #: (<)6 I () L/
I
Phone #:
7t-{ !P--5c...f?C;
. Zip: q 74Y
State:
ore-
~minary Inspection is $15.00 (prior to installation of insert)
~Wood..~~e/Pellet/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: INnndS~~~
Contractor: fy,7)d. (/).p(:lJ h/lp.h. 2 -p Y7-c.tc)...c.:M .
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Address: .5322-- mrJ.;V\ ,Sf- Phone #:
Ci ty: 5fY1'--'Y\-t/1Bk:J State: 0 ~
Construction Contractors Registration #: 2&743
74b -lo~2J
Zip: 9'747x
Expires: ~ -Zb -7Q..
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 Wood 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 br;:,:~'=/Jd.
)jWYl/f~ 7Jl/j(hr rA'l1fq _// -F V
sIgnatur Date I
FOR OFFICE USE
REQUIRED ~NSPECTION(S): ~ODStO~LLET/INSERT)', ~RELIMINARY
Date of Application: !J-7~Z...-9r) Job #: ~-; vq()~
Total Amount Collected: 1!71 ~~
Receipt #:
r 7/ t,-II
Issued By:
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Checked for Delinquencies:
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Checked for Historical Status: ~