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HomeMy WebLinkAboutPermit Miscellaneous 1992-8-10 J~.' . SPRINGFIELD \)0lb ~ ~...r- . VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Offi<;e: INSPECTION LINE: 726-3759 726-3769 Assessors Map Owner: ,f)~/VI/W/A //J27 f)w//./ f);,;~ 1I: \~ffio5a4- Tax Lot 1I: oi()\ro Job Location: JU.",A/'./L/J-n) Address: /0,2'7 1l0~ ~ City: +),/;'#..11"/./ State: (jj( Value' of(\lood Sto~Pellet Stove/Insert:~&; m./)O (please cire1e appropriate appliance) Phone 1I: 7t/t. -3 -<).:zg Zip: 97Y7ff Preliminary Inspection is $15.00 (prior to installation of ,insert) \lood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25 Type of Inspection Requested: ~ -I~~~jI~~;f~~ Contractor: 415(1~ (I/;/;'~/11//./ v&A'LL~b Address: /0, ;!j~ 2::? <7Jt,f/ state surcharge. Phone 1I: 9::f7- 3 936- Zip: 97</1);t. IS' 5/9:< Ci ty: . Z./.I..f~ I Construction Contractors State: ()/f:; Registration 1I: ~q)PO~ 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 \lood'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. i? Wit-eLl (). J)0t Signature ' 0 .9- /{)-P.L- Date' FOR. OFFICE USE REQUIRED INSPECTION(S):~O~S~)PELLET/INSERT ~ Date of Application: K . \C)q~, ' Job lI: Total Amount Collected: ,~. '1S '-- ,1 - Receipt 1I:5~2. Issued By:r-J\U\f\ '"' PRELIMINARY qBIrf37 ~ Checked for Delinquencies:_ Checked for Historical Status: