HomeMy WebLinkAboutMiscellaneous Application 1991-5-9
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.... .sPRiNGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
. CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
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225 Fifth Street
Springfield, Oregon 97477.
Office: 726~375i
.'. INSPECTION ,LINE: '726-3769
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Job Location:
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Assessors Map I: '\lOa3~~
Owner: ' \)) q ()\\ l\(\i.JP~ .
Address:' 4C\~~ .~ i D.\,~~ ,a, Phone I: l1.J:o~aLD\':
City: 61J~ . state,) (~Q ()1~. Zip, q 141?J
Value of Vood Uove/pellet Stov /'Insert. ,r:::.\()C:f:) 0 . .
(please circleap'propriate a pllauce)
Tax Lot'l:
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P~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.
, Type of Inspection ReqUested:~ ^ Q \ i:f'(\ , , ,
, '..:' Contractor: ,CD. 0{\ Q P ) -
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Address:
Phone #:
City:
State:
Zip:
,Construction Contractors Registration I:
Expires:
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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 unders,tand that if I am
requesting a preliminary inspection, the vall covering may be required to be removed.
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Signature ' , ,
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Date'
FOR" OFFICE USE
Receipt
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VOODSTOVE/PELLET/INSERT
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Issued By: ~(ffi.-)
Job I:
PRELIMINARY ~
0{ 10,4 {(A~,'
REQUIRED INSPECTION(S):
Date of Application:
Total Amount Collected:
Checked for Delinquencies:
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Checked for Historical Status: I/'"
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