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:
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