HomeMy WebLinkAboutBuilding Miscellaneous 1991-6-13
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SPRINGFIELD
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Offic;e:
INSPECTION LINE:
726;-3759
726-3769
Job Location:
'2 '2 9i:6
7J~BR.P &.
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Assessors Map 1I: /7 -L)-=J -<? t:. --/ /
Owner: . 5:?A:.A/ _?# #' Pc::::?? '5:::>/5,/
Tax Lot 1I: O.::?<=;cC
Address: ~~tE .
City: .c5 ?r/~0
Phone 1I:7'-1 7-cO-:;:>~
State:
6?=?
/ nr"X"'\
Zip:
Value of~Od Stov~Pellet Stove/Insert:
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of -insert)
(Q60d Stove~Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
Type of Inspection Requested: ,EY/57: ~f"';p~;<p W~:>.?'="y~
Contractor:
Address:
Phone 1I:
City:
State:
Zip:
Construction Contractors Registration 1I:
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
SreqU~in~g a prelimi y inspection, the wall covering may be required to be removed.
t3vv.. to - /3.' f I
~iure (J . Date'
FOR. OFFICE USE
REQUIRED INSPECTION(S):~PELLET/INSERT PRELIMINARY
Date of Application:~-/~-""'7/ Job II: 9/06:20
Checked for Delinquencies:
2b.:2~
--
Issued By: ~~_;,. ,~~
,> I /' ~
Checked for lIistorical Status:
Total Amount Collected:
Receipt 1I: -:<o3C; ")