HomeMy WebLinkAboutPermit Mechanical 1991-3-12
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VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Offi~e: 726~3759
INSPECTION LINE: 726-3769
Job Location: "/3" vtIlA "VI <-I-. (rt"'IAj f.'l-JrP
Assessors MapD: ;1#;M, '/707.. 3y LII .., Tax Lot D:
Ollner: . FI'-tJ.." 1< G. ~ t+ e"V' / R.w.f tv-
Lfli1~ Mc.1< /.M'L"(/ Hw'-1
Address:
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City: :) p.l""',\ f,-pltP State:
Value o~od S~fllet Stove/Insert:
(pie~~~lc appropriate appliance)
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G I't..j {3 LV'o" ij ev" '
Phone 1I: ~ n, 3 '/ 31
Zip: ?1 ~ y(
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Pr.eliminary Inspection is $15.00 (prior to installation of .insert)' ~ ~
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge. t ~,t~
Type of Inspection Requested: {y\_{LAV'fUACe.. 1 ~
Contractor: (y ,..s t ''^j<-L ,II'> - -rr €. ~ stz;., O'1U(,'"I)
Address: Phone D:
City:
State:
Zip:
Construction Contractors Registration D:
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 lias provided lIith the Vood'Stove Safety information for lIood burning
appliances and preliminary inspection standards. I also understand that if I am
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Signa ture Da te
FOR. OFFICE USE
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REQUIRED INSPECTION{S):C:VOODSTO~PELLET/INSERT
Date of Application: ::;; -I'j-q/
Total Amount Collected: Z{g - ~5
Iq(.(~ 3
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Job D: q /()/'~7...J)
PRELIMINARY
Receipt D:
Issued By:
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Checked for Delinquencies:
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Checked for Historical Status: ........---