HomeMy WebLinkAboutPermit Mechanical 1991-7-24
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF 'SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Offic;e:
INSPECTION ,LINE:
726:-3759
726-3769
Job Location: ~\ \ \ ,,\ ~, ~\ ~ n , dn
AssessorsJ.ap I: \R~C)3~~ ." Tax Lot I: O/2(X)
Owner: . bD...u.\ ~ ~C\ ffi CLl j
Address; f"~~tt ~fJ\ '" ~N\\(\Q -Phone I:
City: ~~I'9-' State: ~ Zip: ~---'<()
Value of Vood sJe/€llet ~to~/Insert: I f)qq DO
(please ci rcleal'l" UI'..Q.S appliance)
Pr.eliminary Inspection is $15.00' (prior to installation of ,insert)
Vood Stove/Pellet/Insert Permit i~15'ROA+,$10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested: ~ ~~~
Contractor: 6o~ , \~ -/
A~dreSS:C/~, ~~-/) T)~ \I;:\l\~l 1\ _, Phone I:~\l, r lo~j ,
City: ~:tlcil . State: ~ Zip:c(l41?<('
Construction Contractors Registration I: C'\')~ EXPires:g~ 10. q.:}.
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.
~_,4~h-t2~_
J ' , FOR_O~ICE USE
Date
REQUIRED INSPECTION(S) :1~O~~E~i~NSERT. k: ) .( --rIE, OLIMOAR(.Y()Q /'
Date of Application: ~ . . ' Job I: -I (") [)
Total Amount COllected:~(O - ~ ~ ;, ~ ;~ ^ ')"
Receipt I: ~~ Issued By: ~~(~ I( A
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Checked for Delinquencies:
Checked for Historical Status: