HomeMy WebLinkAboutPermit Mechanical 1991-6-11
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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
Office: 726~3759
INSPECTION LINE: 726-3769
Job Location:
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Assessors Hap I: . ) J O~ ";)./ Lj 4
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Ci ty: ~ State: ()I.fZ
Value of ~. Stov /Pellet Stove/Insert: 51 /OO()
(please c rcle appropriate appliance) 0J;vC{~ ~s,~~
preliminary Inspection is $15.00' (prior to insta1latioQ)of .insert) "
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
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Tax Lot I:
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Ollner: .
Address:
Phone #: ILl) - / 'X ~~
Zip:
'Cfl47/
. Type of Inspection Requested:
atLl40-
Contractor:
Address:
Phone #:
City:
State:
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 lias provided lIith the Vood'Stove Safety information for 1I00d 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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~~~1e "Date'
FOR. OFFICE USE
REQUIRED'INSPECTION(S): ~~E/PELLET/INSERT ,~
Date of Application: ~-II -0 I Job I:
Total Amount Collected: ~1'.:l.{P.d.<::::.
PRELIHINARY
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Receipt #: "^)o'2.'-fX'
Issued By:
1GB
Checked for Delinquencies:
x
Checked for lIistorical Status: Y