HomeMy WebLinkAboutPermit Mechanical 1990-7-24
~..
.
SPRINGFIELD
l)6p
.
WOOO 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: d R,:J-Y c: <:2.--= e Fa,eh/ !2q/
Assessors Map II: 17 0'< c:?OJ.-<-fd /'/00 Tax Lot II: //0 <:)
Owner: /-..Jelen L.",dc:re.h -J"./'c L..'Jdyt"<:..... uJl k.
.Mdress: I /<f;;J., ~ S. W, (-?rel1l1--'1A--r1 k Phone II: &, 3 (; .. 900 ~
City: {J CJ~.I-) 41"\ J I State: (9 (" E' Zip: 9 7 a./ '7
Va 1 ue of Wood Stove/Insert: '~ .!3:ff) ,00
(please circle approprlate appllanceJ
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: wood-s-bue.- {Jc-r """, I
,
Contractor: L\ 'A K ('\ OL.U .......
Address: Phone II:
City:
State:
Zip:
Co~struction Contractors Registration II:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as
required (726-3769). I also state that all information on this application/
permit is correct and that I was provided with the Wood Stove Safety information
~WOOd burning appliances and preliminary inspection standards.
tM-a...R-<I d1'VLt9~<>l/oo.. a.~ J,ry I9-U t--r1.Vr ' 7 - .;L '-{ -'7'0
19nature V (j 0_ uate
FOR OFF ICE USE
REQUIRED INSPECTION(S):
_ STOv'EpINSERT
'I-Q4 -q/)
\S,f'\~
Date of Application:
Total Amount Collected:
Receipt #: I~
Issued By:
PRELIM I NARY
q()()q~( (1
~rf\o..j
Job II:
Checked for Delinquencies:
L---""
Checked for Historical Status:
~