HomeMy WebLinkAboutPermit Miscellaneous 1990-11-28
,..-
. ,
:'llllIIII
=..
SpaFIELD
~,
~
.
YOOD STOVE/INSERT INSPECTION APPLICATION
. CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
. . .
\J~
225 Fifth Street
Springfield, Oregon 97477
Offi<;e:
INSPECTION LINE:
726-3759
726-3769
Job Location:
iall D;{ie. Dr
LSZ -n2-h,t:;- ::< ~
Owner: . KnncJd r; 'i\- M\~;o.-w, A QJ/1I?.fYl'l1A..v\
Address: 10\ \ I'd-I'.U oj> I)Y- \
0?Y'''''-~r{c-d&
.. Value of Yood Stove/Pellet Stove.(Insert)
(please circle appropriate appliance)
Assessors Map #:
Tax Lot I:. 'O/IDD
City:_
State:
Dlt-
C)(m~
Phone #: 1;)..&- 54-01-
Zip: <1i'-1l&'
,
Pr.eliminary Inspection is $15.00 (prior to installation of -insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 state surcharge.
,_..-1-~~. - __...:.-......__,~ ~.~.="'.-.......-..T..- """-~.,._...L::.....-.~...L..;() '_~_'~.r._~-{_'"."".."'~_'_'-J'''~~ -...~~...........,.~_"lo-_'~ ,..:....-....C,.. ..I_~'"
}ype of Inspection Requested: 0'v"'(ll/ij.Q,:1l>r \dlxxjr)ffiNC'~I""-&4It-
Contractor:
Address:
Phone I:
City:
.Sta te:
Zip:
Construction Contractors Registration #:
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 Yood'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.
~~ nll,nD.-~ _..
Signature ~ ~r'~.
JI-ZX J{O
Date'
FOR_OFFICE USE
REQUIRED INSPECTION(S): YOODSTOVE/PELLET/INSERT
Date o( Application: D_- I, '--i .0.7)
Total Amount Collected:~~~ c>i)
Receipt #: IAq 3Pf
Job #:
PRELIMINARY
1.() I L/JaE
V"/
Issued By:
(jvVvv~
'-\
Checked for Delinquencies:
Checked for lIis torical S ta tus:
~