HomeMy WebLinkAboutPermit Mechanical 1991-02-17VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPllIIr|GFIELD
0fflce:
INSPECTION LINE:225 Fifth Street
Springfield, Oregon 97 477
726-3759
726-3769
C'TY OF SPNTruGFIELD,OFEGO'V
Assessors MaP S:/2 ^23 .?q^ 4/
aJob Location:
Ovner:
Ci ty:
Value of llood
(please
Uood St
Tax Lot *:
Address z 2,5 ;3i lU< 2*'ef ' Phone *z V6'7€T
State:zl
pllance)
t/Insert Perm 1t ls 15.00 +.00 Issuance +.25 state surc harge.
Type of Inspection Requesteaz Vfa'6?:7-
Stove/Pellet Stove
clrcle aPProPrlate
/T
ap
nsert 3
lnsnaIn Ilatlon of .lnsert
Contractor:
Address:Phone fi:
Ci ty:State:ZT p:
Construction Contractors Reglstration *3 Explres:
l?-? /
gna ture Date
FOR. OFFICE USE
REOTTTRED TNSPECTI0N(S) :IIO O D STOVE / PELLET / TNSERT PRELIUINARY
Date of Appllcation:Job #:
Total Amount Collected:a+
Receipt #:2 2,,/
By signing this permlt/applicatlon, I agree to caII for an lnspection(s) as required
(726-3169). I "i"i" thai'aI1 inior*utfln on this app!'lcatlon/permlt ls correct and
that I was provided vlth the Woodrstove Safety infoimation for vood burnihg
;ppir""""; ;;e frellminary inspeetion standards. I also understand that if I am
requesting a preliminary in"p""iion, ttt" vali coverlng may be requlred to be removed'
-'hecked for Delinqueneies:
fssued Dy:
Checlced f or llistorical Status:
X
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