HomeMy WebLinkAboutPermit Mechanical 1991-9-16
.
.
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
c
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Offi~e: 726-3759
INSPECTION LINE: (726~3769)
Job Location:
Q3cf fJ(Ump/c <3!-'
~
Assessors Map 11: I I/"):<" ':>/",y -:J Tax Lot 11:
Owner: "Ji)hY') -81f'J~I- . 'Benni Ylyr-
Address: q2.,Lj ~ ILl (O~' Phone 11:
, 'f
6YQO/
City:
Sf 6"
State:
ni).
I Lf J - on ,EL
Zip: Of/WI!
Value of Vood Stove/Pellet Stove/Insert:
(please circle appropriate appliance)
~i~ Inspection is $l~prior to installation of .insert)
Vood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
,
Type of Inspection Requested: p^l! ':!J~
Contractor:
()lJ.!V\o,r
Address:
Phone 11:
City:
State:
Zip:
Construction Contractors Registration 11:
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
requesting a preliminary inspection, the wall covering may be required to be removed.
~~
'Signa ture /
~nH:'~A
o
9-/~-?'/
Date'
I
FOR. OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
Date of Application: C1 / Jl.?It1 I Job 1I:
Total Amount Collected: I <:.no
PRELIMINARY ~
OJ I /0 9S
Receipt II: ').13./0
Issued By:
~
Checked for Delinquencies: x---
Checked for Historical Status: \K