HomeMy WebLinkAboutPermit Mechanical 1990-6-7
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YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: Sic:.... ~Ct/V\I..tL-Y PJ.
Assessors Map #: \10-:2.,").,4)'2 Tax Lot #: ll/lJtJO
Owner: V\' I C' MClt;' n.J \/Ch/\ I j.(,... IA',V\; v-.....,
Address: c.,,<, )()~'A1~.J P.1 . phte #: ,Lt{L:J.'2.,';J.03
City: ~d. State: oQ Zip: 9/'-1'/1
1./ -
Value of Yood Stove/~et"~eVIn;ert:L2J ,700"'"
(please circle appropriate ~e)
Preliminary Inspection is $15.00 (prior to installation of insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: ~ .Y1~el/+ )D..IftJ~ SI.I)v..R..
M~~ I
\A). 1.,.,..eN
Contractor: C'_ \.-'O\..c+
I ~/c.,
C( -t...U:V ~n 0 _
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Construction Contractors
State:
o'R
Phone #: L.., 9e.. . () <;, 3. 3
Zip: qi '-I O'J.
Expires: 10/ ::J9.lq(J
Address:
City:
Registration #: Y lac../")~
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 Yood 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 remo
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Signature
1/O.jJ1{)
Date
FOR OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE~~INS~ ~ PRELIMINARY
Date of Application: ("h\l1t) Job #: qOOl1 ~
Total Amount Collected: IS. IS. ~*
Receipt #:_11-::).1:1 Issued By: QB
Checked for Delinquencies:
..-
.Checked for Historical Status: ---