HomeMy WebLinkAboutPermit Mechanical 1990-12-04IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
!SPFINGFIELO
0ffice:
INSPE TION LINE:
225 Fifth Street
Springfield, Oregon 97477
726-3759
726-3769
OREGONCITY OF
Job Location:
Assessors Hap #:Tax Lot *: O Z7A)
0wner:
Address:Phone *:
Ci ty:State:0e-zlp ,Qz q77
Value of llood Stove/Pellet S 0
(please circle approprlate a
Prellminary Inspection is S15.00 (prlor to lnstallation of insert)
llood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:
contracro ,,DU,l \lJ I l,lh+(
nser
Address:3286 ll nAtur>t ltt k Phone #:
Ci ty:)State:l) Y-'zlp , Q7 ,{05
-T-
Constructlon Contractors Reglstratlon #:F( if : 'xPlres' ='{--.,,/
ql
ta- q- 3()
Date
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769>, I state that all informatlon on this appllcatlon/permit is correct and
that I vas provided vith the llood Stove Safety informatlon for vood burnihg
appliances and prellminary inspection standards. I also understand that if I am
requesting a preliminary inspectlon, the vall covering may be required to be removed.
2-o K.A
Signa ture U
FOR- OFFICE USE
Date of Application:
Tota1 Amount Collected:
REQUIRED INSPECTI0N(S): II0ODSTOVE/PRELIMINARY
Job *:L
Receipt *:It87e
Checked for Delinquencies: L
fssued By:
Checked for Historical Status z vz'
u6*F X
SPBINGFIELD
0ffice:
INSPECTION LINE:
VOOD STOVB/INSERT INSPEgTION APPLICATION
CITY OF SPRINGFIELD
BUILDtrNG SAFETY DIVISION
225 Fifth Street
Springfield, 0regon 97477
Job Location:3
726-3759
726-3769
LA tu3r
Assessors Map *:t10 Zrl 33 Tax Lot *:O-Z7D
Ovner:
Address:Phone *:7/b <58
Ci ty:State:DiL*Zip:
Value of llood St Pellet S
(please circle approprlate
Prellminary Inspectlon is S15.00 (prlor to installation of insert)
Uood Stove/Pel1et/Insert Permit ts $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:rL
Contrac tor:u
Address:*:
,l
e
ft4Ci ty:tate:Zipt
Construction Contractors Reg istratton *: fl1t I Expires:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all informatlon on this appllcatlon/permit ls correct and
that I vas provided r,,lth the llood Stove Safety information for vood burning
appliances and preliminary inspection standards. I also understand that if I am
requesting a preliminary inspection, the vaII coverlng may be required to be removed.
tt- t1-1d
gnature Date
FOR. OTFICE USE
CITY OF SPR OREGON
nser
REQUIRED INSPECTION(s) : IIO0DST0VE /PELLBT lINSERT
Date of AppI t"^ttq", ll - l? '?0
Total Amount CoIIected:fl
Receipt *, 187 Zr:'
PRELIHINARY
Job S:00
Issued By:L'r
Checked for Delinquencies:Checked for Historical Status, n'
v €--