HomeMy WebLinkAboutPermit Mechanical 1991-1-14
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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: gO? ~~
Assessors Hap 1I: \ ~03{J( n4Q
Ollner: . An ~,_ ; --",/\'>11 ~ ~ ~
Address: !?O"} ~"" " )
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City:~ )f~'P~~
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
. Tax Lot
1I: Q4(-fY )
State:
1J{0
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Phone 1I: ?'-/t.- 7~~Ei
Zip: e:r 7(/7 '7
Preliminar~pection s (prior to installation of ,insert)
Vood Stove(!ellet/Insert Permit $15.00 ~ $10.00 I~nce + $1.25 state surcharge.
, Type of Inspection Requested:~ \ III ~ >.0f\ * ~<xlet-
Contractor:_ '- ~(\t'\) ~ ~ M\(~ \.0 J:\
A~dress: 4.h~ 0b~ \_~ _ (j Phone 1I: 54- ~ ~'1'5')
Ci ty: ? ~ "(\t 1\ ~ State. (lJJ?J Zip: Q140]
Construction Contr~ctors Registration 1I: ::)4 ~ ~t:) Expires.n ~I q '-!3.. \
~ 'I J
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/permi t 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
requesting a preliminary inspection, the wall covering may be required to be removed.
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FOR. OFFICE USE
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REQUIRED INSPECTION(S): ~NARy) L/'
Date of Application: / - ! 4 - Job 1I: Y I rXJ] ~
Total Amount Collected: 4\ I~ II ~
Receipt 1I: \C{rY't'=\ ~ed BY:C:~~)
Checked for Delinquencies: Checked for lIis torical Sta tus: