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HomeMy WebLinkAboutPermit Mechanical 1990-10-22 ,= . . SPRINGFIELD VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 Job Location:_! Cj,7y) /11I.L./z.-f'.f-S'- Assessors Map II: 170:; 2J5 =3 2- Owner: flfl 1,\r1 It. . l~vU.Mr!(fck- Address: 11?:iV '/IVLrLi/Ld- S!- Ch" <:'~:zf;' ri ".." DP- Value ~f if. od Stove ellet Stove/Insert:'~Z:V2> _~ (please ClrCle appropriate appliance) * Tax Lot II: () 2/n 0Tl Phone II: 7 if 0 - I ro (I ~ Zip: q7477 Preliminary Inspection is $15.00 (prior to installation of insert) ~od Sto1ne<Pellet/Insert Permit is $15.00 +~state surcharge + $10.00 Issuance (f ,."J.6 Type of Inspection ReqUested:Jl1lJ17d~Jj) J -&,..p.f '*'f>ld"il15 Contractor: _P)(IS-hI1't Slm/p Address: Phone II: City: State: Zip: Construction Contractors Registration II: Expires: By signing this permit/application, I agree to call for an inspection(s) as required (726-3769). I state that all information on this application/permit is correct and that I was provided with the Vood Stove Safety information for wood burning appliances and preliminary inspection standards. I also understand that if I am Z2J~' ~:J~~J::"iO"' ". .,11 .om'..~, b~:;~~;; b. m...d. Signaturl:) . -::-:::---. Date FOR OFFICE USE REQUIRED INSPECTION(S): ~ODSTOiiEJELLET/INSERT '7' PRELIMINARY Date of Application: 10 -l.:z...-Cfo . Job 1I:C;nI26 g v ~ Total Amount Collected: 7Jr-. .7t:; Receipt II: 19;t)T~ Issued By: o JI^^^P_ Checked for Historical Status: .,-/ Checked for Delinquencies: /