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HomeMy WebLinkAboutPermit Mechanical 1991-06-10CITY OF OREGON IIOOD STOVE/INSERT INSPESTION APPL CATION CITY OF SPRINGFIELD BUILDING SAFETI DIVISION SP'TtNGFTELr) 0fflce: INSPECTION LINE: 726-3759 726-3769 225 Fifth Street Springfield, 0regon 97477 Job Location:a ,* Assessors Map t, /'7"OV ,76" ? :1 Tax Lot *: 0wner: Address: l/ 7l l\18 Phone *: Ci ty:4ert>State: d)4 zlp: I Value of Uood Stove/Pellet S (please circle appropriate app ance Prellminary Inspectlon is $15.00 (prior to lnstallatlon of-insert) llood Stove/Pellet/Insert Permlt is $15.00 + $10.00 Issuance + $1.25 state surcharge. Type of Inspeetion Requested:?* *- -pt<- Contractor: L @ert Address:Phone *: Ci ty:State:zl p: Construction Contractors Reglstration #:Explres: reques t this permlt/applicatlon, I agree to call for an lnspection(s) as requiredI state that all lnformatlon on this appllcatlon/permlt is correct and provided vith the llood Stove Safety informatlon for wood burnihg and prellminary inspectlon standards. I also understand that if I am a prlltrtn.ry irrspettlon, the vali coverlng may be requlred to be removed. C'/0^?r Date FOR. OFFICE USE By signing (726-376e). that I vas appliances t (-- REOUIRED INSPECTION(S) : Date of Applicatlon: Total Amount Collected: Receipt *: TIOODSTOVE/PELLET Zro-q./Job *: ?/aS2g 7a7>7 Checked for Delinquencies: Issued By: Checlced for Historical Status: <---- //8u