HomeMy WebLinkAboutPermit Mechanical 1990-09-24CITY OF SPF"VGFIELD, OBEGO'U
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPF!T{GFIELE,
0ffice:
INSPECTION LINE:
225 Fifth Street
Springfield, 0regon 97477
726-3759
726-3769
Job Location:f.^ *
Assessors Map # llOZZud Tax Lot *z hZ 1OC
Address:Phone *: 7?4 - ZqYS
Ci ty:a"l sr.atez t) {j-zrp:9ZqZl
Value of llood Stove/Pellet Stove/Insert:
(please clrcle approprlate appliance)
Prellminary Inspection is $15.00 (prlor to installatlon of-insert)
Uood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:
Contractor: 0 t-,fj li er,r
Address:Phone *:
Ci ty:State:ZI p:
Construction Contractors Reglstratlon #:Expires:
By signing this permit/applicatlon, I agree to call for an inspection(s) as required
(726-3769). I state that all informatlon on this appllcation/permlt is correct and
that I was provided vith the llood Stove Safety informatlon for wood burnihg
app
req
Iiances and prellminary inspection st andards. I also understand that if I am
ues t ing a preliminary inspection, the wali covering may be requlred to be removed.
e--2+- Vo
ature Date "
FOR. OFFICE USE
REQUIRED INSPBCTION(S) : II00DST0VE lPELLET/INSERT PRELIMINARY
Date of Applicatlqn:? zt -?a Job *:
Total Amount Collected: I .€D
Receipt *:Issued By:
Checked f or Delinquencies i ..-Checked for Historical Statusr .''
ovner: .Da L( i e. I 5 (ora/-,