HomeMy WebLinkAboutPermit Mechanical 1990-01-26N\q-(-C't^-
SPFII{GFIELO
I^IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springf ield, 0regon 97 477
Offi ce:
INSPECTION LINE:
726-3759
726-3769
CITY OF SPRINGFIELD, OREGO'V
{vJob Location:
Assessors Map #:Tax Lot #:
Address: /7GLl l,,l S(Phone #: Z4 - S S'a X
C'ity:
Val ue of
(pl eas e approprTate appTfance)
Preliminary Inspection is $15.00 (prior to 'installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
tnd SAor-&rrt)]e
&
State , C r?Zi p z 77{7 7
msertft)o
Type of Inspection Requested:
Contractor: (' ,, ,,,
Addres s :Phone #:
City:State:zi p:
Construction Contractors Registration #:L)Ex pi res :
By signing th'is perm'it/app
required (726-3769). I al
for
Date of Appf ication:
Total Amount Collected
Job #:
licat'ion, I agree to call for an inspection(s) as
so state that all information on this application/I was prov'ided with the Wood Stove Safety informationpermit is correct and that
burn'ing p l'iances and pref iminary inspection standards.
gna ure a e
FOR OFFICE USE
REQUIRED INSPECTION (S )I./OOD STOVE/INSERT PREL IM I NARY
,o.tcm
C
\\)
Issued By:Rece'ip
Checked for Del inquencies Checked for Historical Status:
owner: Ll""I lt4ntt:..