HomeMy WebLinkAboutPermit Mechanical 1990-11-7
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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: f~ ~~?JL-t/JJ.
Assessors Hap ,lI: /71J.'2, "2.'4 /4-".-:- ~.
Owner: J)<Jn-h, /VJ ,}J l/ t/4 /
Address: 5?oo k-t//u ./JJv-J,
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Ci ty:. C;~Y/)".,.J:;.e. j.; State:.d!t---
Value ~f ~~~~/pellet Stove/Insert: ~\i~
(please circle appropriate appliance)
Pr.eliminary Inspection is $15.00' (prior to installation of ,insert)
Wood Stove/Pellet/Insert Permit is $15.00 + $10,00 Issuance + $1.25 state surcharge,
Type 'of Inspection ReqUested:~~ ~~
Contractor:~Y5 6L>. ~A.J S~
Tax Lot I: ~ /d?J
Phone I: 7/t-- 5"..< </ U
Zip: tJ 7V 7 '7
Address:
Phone I:
City:
State:
Construction Contractors Registration 1I:
,,!-Z-Z2-~
Zip:
Expires: \\.:l Or)
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 unders,tand that if I am
requesting a preliminary inspection, the wall covering may be required to be removed.
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Signature ./ ,/', '
~..z~/97'd
pate '/
FOR, OFFICE USE
REQUIRED INSPECTION(S)~VOODST~PELLET/INSERT ~PRELIHINARY
Date of Application: Q-2.4-9n Jobll: On//75
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Total Amount Collected: Z&; . Z.s-
Checked for Delinquencies:
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a#K40/~ _
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Checked for Historical Status:
Rec'eipt I: /~ ~ ft:,
Issued By: