HomeMy WebLinkAboutPermit Mechanical 1991-7-24
e
...
-
VOOD STOVE/INSERT INSPECTION APPLICATION
, '
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
, ,
Springfield, Oregon 97477
Office:
INSPECTION ,LINE:
726:-3759
726-3769
- '
J~b Location: tS\.o\_QC) \ )()J~~__,N~) ~~
Assessors ~ t: \ 9/)8 _, . ',~ . Tax Lot
Owner: ' '(--AX)2 f\~ [\, m I
Address: ~\O\~) ill LeU 4:'0'l
City: ~ ' Stat~ l\JAQ fl1\
Value of Vo d ve/Pellet Stove/Insert: \ \_ 0 ~ DO
(please circle appropriate appliance)
Phone
I: ()(O\ l~
*: l4(o-~()
'Zip: ~,
"
P~eliminar ion is $15.00 (prior to installation of -insert)
Vood Sto, , sert Permit is~.OO + $10.00 ~ssuance + $1.25 state surcharge.'
Type of Inspect' n Requested: J-(~ _ ~ 1 '
Contractor: ,'" ~
'~()'2.? ~ \'\\~ _, 'Phone *:_022/'
N,State: [\JL Zip: ql~ 1 '
:aClors Registration 1:~-3-ExPires: 56. .2.\.0. ~~.
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 understand that if I am
re, sting a preliminary inspection, the vall covering may be required to be removed.
( , '
;j
"
Address:
C. J
lty:
A- '
" FOR. ~ICE ~E-
Date
./
REQUIRED INSPECTION(S): VOODSTOVE/ ELLET. INSERT ~
Date of APPlicatiQn:~7 - .' JOb"l: q \D<X'} of)
Total Amount Collected: 'c!;)(o. a~:':' A' .
- (rr/1U~dBY: ~L)V
Checked for Delinquencies: ~ Checked for IJistorical Status:
PRELIMINARY
. ,
, ,
Receipt
ftml~~
"cp
. . c..........
,