HomeMy WebLinkAboutPermit Mechanical 1990-09-25ITOOD STOVE/INSERT INSPECTTON APPLTCATION
CITT OP SPRINGFIETD
BUILDING SAFETY DIVISION
SPFIIYGFTELD
0ffice:
INSPECTION LINE:
225 Fifth Streer
Springfield, Oregon 97477 726-3759
726-3769
CITY OF
tst
Job Location:
Assessors Map *:
Ovner:
Address:v
r rax Lot *: 4hM
Phone *:14 1- [1 lD
City:
VaIue
State:
ert:
ea pr a te appl iance)
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(please circl
Pr.eliminary Inqpec
lJood Stov e/Pr{L$/(---'
Con trac tor:
Address:
Ci ty:
of llood St
l1/ t r^
*6uL
Type of Inspeet on Requested:
tion is $15.00 (prior to installation of.insert)
rnsert Permit is $15.00 + $10.00 rssuance + $1.25 state surcharge.
frlllul- Staru
Phone $:
State:?z{azzip:
Construct ion co(tactors Reglstration #:Expires , /0'2tr: ?a
By signing this permit/application, I agree to call for an inspection(s) as required(726-3769). I state that aII informatlon on this applicatlon/permit is correct andthat I vas provided vith the llood Stove Safety information for wood burnihg
appliances and prellminary inspection standards. I also understand that 1f I am
requesting a preliminary inspection, the vali covering may be requlred to be removed.
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FOR. OFFICE USE
REQUTRED TNSPECTTON(S) :PRELIMINARY
Date of Applicatlon:Job #:
Tota} Amount CoIIected:
ls5Receipt S:b0
Checked for Delinquencies:
Issued By:
Checked for Historical Status: