HomeMy WebLinkAboutPermit Mechanical 1990-07-19a OREGO'V
!;PRIilGFIELE,
llIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISiON
225 Fift.h Street
Springfield, 0regon 97477
Offi ce :
INSPECTION LINE:
726-3759
726-3769
Job Location: /y'Lr- y'LQ. Z4 -- ZZ
-77-
#: /7- 6:3- 26'15----lax Lot #:Dgqd)
11
Assessors Map
Owner:
Address I 2 2 e l.*-]-. Qz Phone #:72b* 5-7?;
c e t-t t+./
-t
State:Zi p:ZZ
.Wood Stovo/
ease circle
Insert, fi%o.@
appro prTatE app TTan ce )
Type of Inspection Requested:
Preliminary Inspection is $15,90 (
, Wood Stov6/Insert Permit is $15.00
Ci ty:
Value of
(pl
Ccrntractor:
rt'inseof
ge
prior to+ $0.75
instal lation
state surchar
a2
/--A-(-e-
Address: ---- Phone #i-
c i t.y ,---_ state:
---z
i p:_
Construct'ion Contractors Reg'istration #:- - Expires:
Bys 'igning this perm'ired (726-37 69) .
'it/app'l'ication, I agI also state thatqu al I informa
p
ft
ermit is correct an d that I was Provided w'ith the
r wood burning aPPl an ces and pref iminarY insPect
7 -7 /]
gna ure
FOR OFFICE USE
ree +"o cal l for an ins
tion on thi
Hood Stove
'ion standar
pection(s) as
s appl ication/
Safety information
ds.
Z)
REQUIRF.D INSPECTI0N (S ) : ,' W00D ST0VE/I NSERT ,.' PRELIMINARY
Date of Application '7- (Q ' f t 0
Total Amount Collected:
Rece'ipt #:Issued By:U,t/\*!---
Checked for Delinquencies:// Checked for Historical Status z -/
CITY OF
Daile
Job #: