HomeMy WebLinkAboutPermit Mechanical 1990-4-27
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office':
INSPECTION LINE:
726-3759
726-3769
Job Location: S' 9'r - A /t.tlf/~ul /Cd
Assessors Hap jj: /7- ()~ - 7 -r-/ ~
Tax Lot jj:
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Owner: r= u.) P
Address: -?az r j J4 A/--l
Phone jj:
City: State:
Value of Vood Stove/Pellet Stove/Insert: 4t t/TlD.O'6
(please circle appropriate appliance' L
Zip:
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested:
CDntractor: Jtt r,f,~ '1Jlj(ttl.1.LiA.
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Address:
Phone jj:
City:
State:
Zip:
Construction Contractors Registration jj:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as
required (726-3769). I state that all information Dn this application/permit is
correct and that I was provided wi th, the Vood Stove Safety information fDr 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 ~ved. ,
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Signa ture I Da te .
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REQUIRED ~NSPECTION(S)~OOq~T~PELLET/INSERT ~ PRELIHINARY
Date of Application: ~ jqD Job jj:
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FOR OFFICE USE
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Total Amount Collected:
Receipt
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Issued By:
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Checked for Delinquencies:
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Checked for Historical Status: