HomeMy WebLinkAboutPermit Mechanical 1991-2-20
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VOOD STOVE/INSERT INSPECTION APPLICATION'
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477
Offi~e: 726~3759
INSPECTION LINE: '726-3769
City:
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Job Location:
Assessors Hap. ,1I:
Tax Lot 1I: () ,?:, Or? Z- '
Owner: .
Address:
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Phone
1I: ,{l.(7-f(/f'''i
Zip: 17<l7?
State:
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, Preliminary Inspection is $15.00' (prior to installation of .insert) ,~
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 ,Issuance + $1.25 state surcharge.
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
, Type of Inspection Requested:
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City:
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Phone 1I:
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Contractor:
Address:
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Zip:
Construction Contractors Registration 1I:
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 Vood'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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Signarure
FOR. OFFICE USE
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REQUIRED'INSPECTION(S): ~~TOVE/PELLET/INSERT
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Date of Application: Z-- - ZO - Cf /
Total Amount Collected: Z.fn, Z I)
~ PRELIHINARY
Job 1I: CJ Ii) / 2., X'.
Receipt 1I: jCi~vl
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Issued By:
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Checked for Delinquencies:
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Checked for lIistorical Status: ..-----