HomeMy WebLinkAboutPermit Mechanical 1991-04-08SPRIltc}:!ELD
},OOD STOVE/INSERT INSPECf,ION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION L,tOB
0ffice:
INSPECTION LINE:
225 Fifth Street
Sprlngfleld, 0regon 97477
726-3759
726-3769
OREGO'VCITY OF
Job Location:I qq). e,lnqP *,^6( c<-,
Assessors Map *:
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l-)t-r1?qaq Tax Lot f;: On3O\-
0vner:
Address:
Ci ty:
Va1ue of
(p
Phone *: 1,+-)-tfL')
State: O Q ztp , 4)q)-)
IetStove/Insert: 1l(),^.o''r cle approprlate appllance)
Pr.ellminary Inspectlon ls $15.00 (prlor to installation of insert)
Uood StoveTpettltZlnsert Permlt ts $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:LO ::&d'.,^.4--
Contractor:D +- \^Y^\*.r # Jq)-lo
Address: Eo,X \oq Phone {: qZ .lt )
Ci ty:Ql^,.,State:or<21 p:q1 q2,-?
By signing thls permlt/applicatlonr I agree to call for an inspectlon(s) as required
(726-3769r.state that all informatlon on this appl lcatlon/permlt ls correct and
that I vas p lded vith the llood Stove Safety lnforma tlon for vood burnihg
appLlances prellml lnspec tlon standards. I also understand that lf I am
requ es ti a lm lnspectlont the valt- coverlng maY be requlred to be removed.
Ll
S gnature
FOR. OFFICE USE
te
REQUIRBD INSPECTION(S) :PELLET/INSERT ,\,PRELIHINARY
Date of ApPllcatlon:r'{ l* \a t Job *:
Total Amount Collectedt 5 3-U }.(
Receipt $zlQ Lal Issued BY:
){
t3
Checlced for Ilistorical Status:
s
Construction Contractors Reglstratlon *: }? )-f 0 Explres t (Dl''-'lt, t
Checked for Delinquencies:Y