HomeMy WebLinkAboutPermit Mechanical 1991-01-07sPF,,NcF'ELE
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}IOOD STOVE/INSERT INSPECf,ION APPL CATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfleld, 0regon 97477
0fflce:
INSPECTION LINE:
726-3759
726-3769
CITY OF OREGON
Job Location:
Assessors Hap #:?.3D,3 Tax Lot *:0L/50e
Phone #, lLu , io Y 0
, 41+l tr
(Ovner:
N).3YLAddress:
Ci ty:
Value o
(p
Type of Inspection Requested:
State:DL z7 p
eIIet Stove/Insert:O
e approp rlate appliance)
Pr.ellmlnary Inspectlon ls $15.00 (prlor to lnstaLlatlon of-insert)
Ilood Stove/Pellet/Insert Permit ts $15.00 + $10.00 Issuance + $1.25 state surcharge.
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to,tt-
Stov
Con tractor:
Address:Phone #:
Citv: State:zlp:
Construction Contractors Reglstratlon S:Explres:
By slgning thls permit/applicatlon, I agree to caII for an lnspection(s) as required
(726-3769). I state that aLI lnformatlon on this appllcatlon/permlt ls correct and
that I vas provided vith the lJood Stove Safety lnformatlon for vood burnihg
appliances and preliminary inspection standards. I also understand that if I am
rlquesting a prlttminary inspectlon, the vali coverlng may be required to be removed.
q-*r,- 7 , /77/
gnature 6;ie'----------'Z
FOR. OFFTCE USE
REQUTRED TNSPECTTON(S) :/INSERT PRELIMINARY
Date of Appllcatlon:Job *:D
Total Amount Collected:
Receipt *:t ?oza
a
Checked for Delinquencies:
Issued By:
Checked for llistorical Status, L/
fuuln^i,
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