HomeMy WebLinkAboutPermit Mechanical 1990-09-05IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIETD
BUILDING SAFETY DIVISION
lsPFII{GFIELO
Office:
INSPECTION LINE:
726-37s9
726-3769
225 Pifth Street
Springfield, 0regon 97477
CITY OF OREGON
Job Location:
Assessors Map *:v {, >?-Tax Lot #:3to o
0vner:
Address:
Ci ty: "ybrl-"^lolC State:
Phone *z 7y,/- e65l
zipz f 7/77-T----7r
Value of Vood St rnsert r#/.77f
(please circle appropriate appliance)-
Preliminary Inspection is S15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Req uested z f,pu).. C"ttl/-h+-
Con tractor:frr*/, J furuet't-n.t -;u
Address:Phone *, 3 44 --A58 e
Ci ty:State:zip:
Construction Contractors Registration *:4 rgat Expires:7/ r/?0
By signing this permit/application, I agree to caII for an inspection(s) as
required (726-3769). I state that aII information on this application/permit is
correct and that I was provided vith 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 covering may be required
to be removed.
Date
FOR OFFICE USE
S
LLET /REQUIRED INSPECTION( S) :
Date of Application:
Tota1 Amount Collected _;5,15
Job #:
Y
/0/
Receipt #:Issued By:
Checked for Delinquencies:Checked for Historical Status:
Ill1
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