HomeMy WebLinkAboutPermit Mechanical 1991-04-05SPRINGF!ELD
IIOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfleld, 0regon 97477
Offlce:
INSPECTION LINE:
726-3759
726-3769
CITY OF SPF OREGO'V
Job Location:z4u= N BqA )+-
Assessors Hap s Tax Lot $:/// o
Owner:
Address:
Ci ty:
o
Z/{z il zlb tk,Phone *:
c t State: CR{zl p:/7/77e
%CD.c()Value of et Stove/Inserts
(please c rc approprlate appllance)
Prellminary Inspectlon ls $15.00 (prlor to lnstallatlon of insert)
Ifood Stove/Pe1let/Insert Permlt ls $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested:
Con trac tor:
Address:Phone *:
City: State:2,1 p!
Constructlon Contractors Reglstratlon *:lres:
By slgning this permit/application, f agree to call for an lnspection(s) as required
(726-3769). I state that aII lnformatlon on this appllcatlon/permlt ls correct and
that I vas provided vlth the llood Stove Safety lnformatlon for vood burnihg
appllances and prellminary lnspectlon standards. I also understand that lf I am
requestlng a pre!.imlnary lnspectlon, the vaII eoverlng may be required to be removed.
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s ture
FOR. OFFICE USE
REOUTRED INSPECAI0N(S) :
Date of Applicatlon:
Total Amount Co
LI -r-7 Job *:tcaLPRELIHINARY
Receipt S:\"1't,
L/t'Checked for Delinquencies:
Issued By:
Checlced for llistorical Status:
tTozl?3t
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