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HomeMy WebLinkAboutPermit Mechanical 1990-5-11 " " ..I; . SPRINGFIELD WOOD 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: G~q.... J tlariDlAJ '[[J) Assessors Map #: /1/D-3---;)I-I,;2., Tax Lot #: p'W r f:rM UXSr- -<<rJP/a1J rPffV + I tA/vcCIL Address: Phone #: ()/q{) 6 f jJ.JJ'lJrm I -ftnW) l~l-q 2.--/S Owner: City: State: Stov /Pellet Stove/Insert: it L)[)6 .00 . cle appropriate appliance) Zip: P~eliminary Inspection is $15.00 (prior to installation WODd Stove/Pellet/Insert Permit is $15.00 + $0.75 state Type of Inspection Requested: !1){)OcL (J1r/rl- M~ V1s I-d1lu) J of insert) surcharge 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 was provided wi th, the Wood 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 ~::'; l?iJuiM-. ,~_ 11_ <fa S1gnature / y' Date . "/) J.L FOR OFFICE USE ~/,- r' P I>> ~------; REQUIRED INSPECTION(S):~E/PELLET/INSERT ~ 6-((-9D /~1s Date of Application: Job #: PRELIMINARY 0J.()~,r (; . Total Amount Collected: Receipt #: 1'7 D;)-C/ Issued By: flA j ) fJ/)/l~ ,..-' Checked for Delinquencies: ..--- ,..- Checked for Historical Status: