HomeMy WebLinkAboutPermit Mechanical 1991-01-15}IOOD STOVE/INSERT INSPECTION APPL CATION
CITY OF SPRINGFIELD
BUILDtrNG SAFETY DIVISION
SPFTI\,GFIELO
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INSPECTION LINE:225 Fifth Street
Sprlngfield, 0regon 97477
726-3759
726-3769
OREGONclrY oF
Job Location:3N DOas frJ
Assessors Ma *:
Owner:
Tax Lot *:
Address:St3 N aolN Phone *:
City:State !a
Value of llood S /rnsert 3' nq<,oo
(please circle ate ap pllance)
PrellminarY I ctlon
Uood Stove
Type of Inspection Requested:
is $15.00 (prior to lnstallatlon of'lnsert)
rt Permit ls-$15.00 + $10.00 Issuance + $1.25 state surcharge.
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Pellet St
Contrac tor:
Ci ty:
Construction Contract
Address:Qo Bo v fso Phone *:
State: Og zlp:
Reglstration #:bro-S-Bxplres:io-q I4
l^ ts-q I
Date
FOR. OFFICE USE
By slgning this permlt/applicatlon, I agree to caII for an lnspectlon(s) as required
(iZO-|tOg\, I siate tt"i'aII lnformatlon on this appLlcatlon/permlt ls correct and
iit;i i'r"" prorided vlth the Uood Stove Safety lnformatlon for vood burnlng
iffft""".s and prellminary lnspection standards. I also understand that if I am
rlquesting a prltiminary inspettlon, the vali coverlng may be requlred to be removed.
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REQUTRED TNSPECTTON(S) :d PRELIMINARY
Date of Applicatlont I - lS-Q I Job S:Qorsd I
Tota1 Amount Colleeted:a L)(
9EReceipt Xz \41fl1
Checked for Delinquencies:
Issued By:
Lat-Checlced for Historical Status:
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}IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
SPRI]\lGFlELD
0ffice:
INSPECTION LINE:
225 Fifth Street
Springfield, 0regon 97477
726-3759
726-3769
CITY OF SPR INGFIELD,OREGO'V
Job Locat ionz '25b1 A( 20-r^ y--
Assessors Map f,: lToz tl Lt Z-Tax Lot *z 0 77 72,
0wner:
Address z 'Zfi/r>4 /\/ 7d-fi^ Sl-Phone *: 74'/DD4Z
Ci ty:State:cL-zl p:?zqzz
Value of llood Stove/Pflie ts
(please circle approprla te appllan
Prellmlnary Inspectlon is $15.00 (prior to installatlon of-insert)
good Stove/Pellet/Insert Permlt is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Req
i
uested 2 pfq t nn r1t1 dail-
contractor: ( r-ofi S#; C" - 0
Address,lo bot Zrjot Phone il:
Ci ty:State:0e ,7t,{oLzlp
Construction Contractors Reglstration *:4b5o5 Ex pt res: l0 -21 I I
By signing this permit/applicatlon, I agree to caII for an lnspection(s) as required
(726-3?69). I state that all lnformatlon on thls appllcatlon/permit ls correct and
that I vas provided vith the Uood Stove Safety informatlon for vood burnihg
appliances and prellminary lnspection standards. I also understand that lf I am
requesting a prelimlnary lnspectlon, the vali coverlng may be requlred to be renoved.
/Q-3t -?o
Date
OFFICE USE
ture
REQUIRED INSPECTI0N(S) : II0ODST0VE/PBLLET/INSERT
Date of Appllcatlonz lL --Arr ,.4O
Total Amount Collected:
Receipt fi:Issued By:
/
LT
PRELIHINARY
Job S:4ot5o t
Checked for Delinquencies:Cheelced for llistorical Status z y'
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