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HomeMy WebLinkAboutMiscellaneous Application 1990-12-28 '. . SPRINGFIELD VOOD STOVE/INSERT INSPECTION APPLICATION' CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 , Office: INSPECTION ,LINE: 726;-3759 726-3769 " I Job Location: ?C/2/ ~,3;>N"~..#' Assessors Hap ,B: I/""b '3 --2. ?..7'2... Owner: C:::tt>R/A/NE :5./>?/.7# Address: ~~~ City: C:::;%>~0'-, State: Value of-Vo~d Stov~et Stove/Ins~ (please ci rc1eap'propria te appliance) 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: ~~-~~~~ Contractor: )E~Lt? 7Fc#~;; ~ ~/~'-0TfJ' A~dress: tlh/:;- Cn~b ~~ ./; ~, Phone B: -=?C/"<-_'J::>.s--::> - ~. .~ City:' r~-~-_State: br-.. Zip: 9??4::>/ ~ I ,. ) . Construction Contractors Registration D: C::;~<f)~ Expires: 9-9/ , Tax Lot B: (!) 76~ Phone B: ~~/' ,C:?;'7.?'~ Zip: .q~c;O :> 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 inspec t ion standards. I also understand tha t if I am requesting a preliminary inspection, the wall covering may be required to be removed. ~~J~:1::lJ.!I.> '-R~;fl) Signature /7 - "< EL"Z-z:;;> Date FOR,OFFICE USE REQUIRED INSPECTION(S): VOODSTOVFq'1lELLEt:YIJSERT), X ~IKi:N~YJ k Date of Application: 12..:?~~ Job B:' 9~./V""" / ~ ' I Total Amount Collected: /!? Y -::X. -:-",r-'" 41:-< --,c __ -"'&>'-- - /' ''">" ..c". __" /---=. \<6~G1c;;.. .---: //' /': Receipt B: ~-'> :.. " > ~ued By:../" -i~.//....-r~_____ , /' [.R'..,~ _ r Checked for Delinquencies: Checked" for 'II is torlcai Sta tus: '-