HomeMy WebLinkAboutPermit Fence 1990-11-14SPRIIIGFIELC,
IIOOD STOVE/INSERT INSPECTION APPLTCATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
0ffice:
INSPECTION LTNE:
726-3759
726-3769
CITY OF SPR OREGON
Job Location:
Assessors Map #:
0vner:
?^//Tax Lot #: A=a
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Address: 3o?G L,J\SIOC Lo"-p phone # 24 t -dlt3
Ci ty:S,;?-lAjLr Fleuyzl State: (1rr zipz eiZ4))
Value of llood Sto PeIIet St rtz /(,Z<'L(please circle hte appliance)
Preliminary rnspection is $15.00 (prior to instarration of insert)
Wood Stove/Pellet/Insert Permit is $15.00 + Estate surcharge + 910.00 Issuance
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Type of fnspection Requested:
Con t rac tor:L I tr, 117
Address:Phone *, (K4 -?rtr \
Ci ty:State:zip z q>/o{
Construction Contractors Registration #:(,>7z,{Expires:
By signing this permit/a pplication, I agree to call for an ins pection(s) as required(726-3769). I state tha t all informatlon on this applicat ion/permit is correct andthat I was provided with the l{ood Stove Safety inf ormation for vood burni ngappliances and prelimina ry inspection standards. I also understand that if I amt ing 1 nspection, the vaII coveri ng may be required to be removed.7Sr lt tr, tt W €+/t b! ll A SsC .
gna ure
FOR OFFICE USE
REQUIRED INSPECTION(S): IJOODS PRELIUINARY
Date of Application:a Job *:/<73
Total Amount Co1lected,
Reeeipt #:
Checked for Delinquencies:
fssued By:
Checked for Historical Status:
6*Sx-f e
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