HomeMy WebLinkAboutPermit Mechanical 1991-07-05IIOOD STOVE/INSERT INSPESTION APPLICATION
CITT OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPRINGFIELE,
0fflce:
INSPECTION LINE:
225 Fifth Street
Springfield, 0regon 97477
726-3759
726-3769
Job Location:6 5,zl 45 ,-i"LI
Assessors l,lap *:)anz 37 44 Tax Lot *: OLSDOJOwner:
Address:
Ci ty:
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State:
Phone #: -?Ltl-]SSZ-
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(mrtsrun€)Value of llood Stove/Pel}et Stove/Insert:crA
(please circle appropriate appliance
Prellminary Inspectlon ls S15.00 (prlor to installatlon of'lnsert)
Ilood Stove/Pellet/Insert Permit ts $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:t,re-c*."* t w- r/ c/ela-P,
Con trac tor:
Address:S *-^ ^-q-.Phone *:
Cityr State:ztp:
Construction Contractors Reglstratlon #:lres:
By slgning this permlt/applicatlon, I agree to call for an lnspection(s) as required
(726-3769), I state that all lnformatlon on this appllcatlon/permlt ls correct and
that f was provided with the llood Stove Safety informatlon for wood burnihg
appllances and prellmlnary lnspectlon standards. I also understand that lf I am
requesting a preliminary lnspeetton, the wali coverlng may be requlred to be removed.
,6u,*LZ L,1-5-?r
Slgnature f Date
FOR. OFFICE USE
REQUIRED INSPECTION(S): IIOODST0VE/
Date of Applieatlon:
Tota1 Amount Collected:, .- a-2<l,/z--. a r
Receipt *, 21 597
Checked for Delinquencies:
PRELIHINARY
Job #:
Issued By:
Lt''-Checked for Historical Status:
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