HomeMy WebLinkAboutPermit Mechanical 1991-12-17
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION:
CITY OF SPRINGFIELD ",'
BUILDING SAFETY DIVISION
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Of~fit;.~;~f.?~:-3759 .
INSPECTIONtINE~'Jt!72 6-3 7 69
225 Fifth Street
Springfield, Oregon 97477
Job Location:
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Tax Lot #:
~(5'CY/
Assessors Map ft: /$ -t::>z -c>0e5Ci'
Ovner:, L J19RR)/ .... fO.u.lf'I fA )f[,:r:.;::;/?
Address: /1")9n L/N'cJa LA/ ~"''ii+?e1d_Phone II:
City: ',. c:;:.PFLD State: ,6R
Value' of Vood Stove/Pellet Stove/Insert: ~. 6 00
(please circle appropriate appliance)
72(g -099.~
Zip: 971/77'
preliminary Inspection is $15.00' (prior to ,installation of ,insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $~state surcharge.
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Type of Inspection Requested~ hilt ()LIKJ{;. .,::{;!? f)EuET L.u'~.:r .
Contractor: (tUBr,:&7nA 1<;: \PiUl,c;=:S.<; l~lI4~ . (' H;mrJl9- ~ltU:;
Address: 7,,, F l\?'''"' Plpne II: Qo(4-QS'"'R'7
City:L~)c-i='Il~~State: n Zip: ([71./0J-
,Construction Contractors Registration ft: (~")72X" 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 vas 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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Sidfdature '1
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Date'
.;7-,9/'
FOR. OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVR1PE1LET/INSERlrJ~
Date of Application:
1;;:'-/7-9/
YO.7~
Job ft:
PRELIMINARY ~
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Total Amount Collected:
Re~eipt #:.'3'7"36.
Issued By:
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Checked for I1istorical Status:
Cliecked for Delinquencies:
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