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:
'-