HomeMy WebLinkAboutPermit Mechanical 1990-12-14
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YOOD STOVE/INSERT INSPECTION APPLICATION
, CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
Offi<;e:
INSPECTION LINE:
726-3759
726-3769
Job Location:
iall D;{ie. Dr
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Owner: ,KnncJd r; 'i\- M\~;o..w, A QJ/1I?.fYY\1A..v\
Address: 10\ \ 1'd1'.J.i oj> 1;)Y \
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"Value of Yood Stove/Pellet Stove.(Insert)
(please circle appropriate appliance)
Assessors Map #:
Tax Lot I:, 'O/'1DD
City:_
State:
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Phone #: 1;)..&- 54-01-
Zip: <1i'-1l&'
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Pr.eliminary Inspection is $15.00 (prior to installation of ,insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
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}ype of Inspection Requested: rrv"'(lIti:IQ.:1l>r \dlXxjr)ffiNC'~I""-&e.vt--
Contractor:
Address:
Phone I:
City:
,Sta te:
Zip:
Construction Contractors Registration #:
Expires:
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 Yood'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.
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Signature ~ ~r'~,
JI -ZX J{O
Date'
FOR. OFFICE USE
REQUIRED INSPECTION(S): YODDSTOVE/PELLET/INSERT
Date of' Application: i,)_- I, '-i -Cz,7)
Total Amount Collected:~~~ c>i)
Receipt #: lf3q 3Pf
Job #:
PRELIMINARY
1.() I L/JaE
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Issued By:
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Checked for Delinquencies:
Checked for lIis torical S ta tus:
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